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A^^^IOGRAPHIC  ATLAS 


OF   THE 


Pathologic  Changes 
of  Bones  and  Joints 


BY 


AMEDEE    GRANGER,    M.    D. 

Lecturer    on    Radiology    and    Electro-physics,    New 
Orleans   Polyclinic;    Physician-in-charge   of   the 
X-ray  Department  of  the  Charity  Hospital; 
Associate  Editor  of  the  Journal  of  Ad- 
vanced   Therapeutics;     Member    of 
Societe  Francaise  d'Electro- 
therapie,   Paris 


NEW  YORK: 
T^^    -A..    L.    OH^TTERTOIS^   CO. 


(2r  If"?- 


Copyright,  1911, 


AMEDEE  GRANGER,  M.D. 


CONTENTS 


PAGE 

Preface   1 1 

Introduction   13 

Skiagraphy 17 

Normal  Joints 27 


PART  II. 

DISEASES  OF  THE  JOINTS  AND  BONES 

Osteo-Myelitis  S3 

Tuuerculosis  67 

OsTEO- Sarcoma  ^^ 

Syphilis    91 

Periostitis    105 

Rickets    109 

Scurvy  117 

osteomata   123 

Osteoid-Chondroma    123 

Cyst 128 

Differential   Diagnosis 130 

Arthritis    131 

Rheumatoid  Arthritis 141 

Tubercular  Arthritis i47 

Loose    Semi-Lunar   Cartilage 158 

PART  III. 

FRACTURES,   DISLOCATIONS,   FOREIGN    BODIES. 

Fractures  161 

Dislocations   183 

Foreign  Bodies ipS 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/radiographicatlaOOgran 


INDEX  TO  PLATES 


\TE  PAGE 

I.     The  Author's  Radiologic  Frame 23 

II.     The  Author's   Radiologic  Frame 25 

in.     Normal   Shoulder  Joint — Antero-Posterior   Position....  29 
IV.    Normal  Shoulder  Joint — Posterior-Anterior  View — Head 

of  Humerus  Rotated  Outwards 31 

V.    Normal  Elbow  Joint — Antero-Posterior  View — Forearm 

in    Supination 33 

VI.     Normal   Elbow   Joint — Lateral   View — Internal   Condyl.; 

Lying  on  the  X-Ray  Plate 35 

VII.    Normal  Wrist  Joint — Palmar  View 37 

VIII.    Normal  Hand — Palmar  View 39 

IX.     Normal    Sacro-Lumbar   and    Sacro-Iliac   Joints — Dorsal 

Position  41 

X.     Normal   Hip  Joint — Dorsal   Position 43 

XL    Normal  Knee  Joint — Antero-Posterior  View 45 

XII.     Normal  Knee  Joint — Lateral  View — The  Leg  Lying  On 

Its    External    Surface 47 

XIII.  Normal    Ankle    Joint — Lateral    View — Fracture    of    the 

Lower  End  of  the  Fibula 49 

XIV.  Normal   Foot — Plantar   View 51 

XV.     Osteomyelitis  of  the  Lower  End  of  the  Humerus 55 

XVI.     Osteomyelitis  of  the  Radius — Presence  of  Sequestrum. .       57 
XVII.     Osteomyelitis   of  the  Radius — Total   Destruction  of  the 

Bone — Secondary  Involvement  of  the  Soft  Parts...       59 
XVIII.     Chronic  Osteomyelitis  of  the  Ulna — Extensive  Destruc- 
tion  of  the   Shaft,   with  the   Presence   of  a   Large 

Sequestrum    6r 

XIX.     Osteomyelitis  of  the  Metacarpal  Bone  of  the  Thumb — 

Involvement  of  the  Soft  Parts 63 

XX.  Osteomyelitis  of  the  Entire  Shaft  of  the  Humerus  Sepa- 
ration of  the  Up.per  Epiphysis — Presence  of  Large 
Sequestra — Secondary     Involvement    of    the     Soft 

Parts    65 

XXI.  Tuberculosis  of  the  Lower  End  of  the  Femur — Sec- 
ondary Involvement  of  the  Knee  Joint 69 

XXII.     Tuberculosis   of  the   Bones   of  the  Wrist — Presence   of 

Sequestra   71 

XXIII.  Tubercular  Osteomyelitis  of  the  Tibia — This  Case  Had 
Suffered  with  an  Undiagnosed  Pain  in  the  Knee  for 
Over  One  Year,  During  Which  Time  He  Was  Sub- 
jected to  Numerous  and  Varied  Treatments 73 


PLATE  PAGE 

XXIV.     Tubercular  Ostetitis  of  the  Tibia 75 

XXV.  Sarcoma  of  the  Soft  Parts  of  the  Thigh — No  Involve- 
ment of  the  Femur — X-Ray  Finding  Confirmed  by  a 
Careful  Examination  of  the  Limb  .After  a  Hip  .Am- 
putation     -g 

XX VT.     Osteo-Sarcoma   of   the   Upper   End   of   the   Humerus — • 

Secondary  Involvement  of  the  Soft  Parts 81 

XXVII.     Immense  Osteo-Sarcoma  of  the  Lower  End  of  the  Femur 

— Involvement  of  the  Knee  Joint 83 

XXVIII.     Osteo-Sarcoma   of   the   L^pper    End   of   the    Humerus — 

Pathological    Fracture 85 

XXIX.     Osteo-Sarcoma  of  the  Femur — Pathological  Fracture...  87 
XXX.     Osteo-Sarcoma  of  the  Lower  End  of  the  Radius — Giant 

Cell    Variety 89 

XXXI.     Syphilitic  Gummata  of  the  Muscles  of  the  Thigh 93 

XXXII.     Syphilitic  Periostitis  of  the  Tibia 95 

XXXIII.  Syphilis  of  the  Lower  End  of  the  Radius 97 

XXXIV.  Syphilis  of  the  Femur — Calcareous  Degeneration  of  the 

Popliteal   Artery — Presence   of  a    Phlebolith   in   the 

Popliteal    Veins 99 

XXXV.     Syphilis  of  the  Femur — Necrosis  of  Bone — Involvement 

of  the  Soft   Parts loi 

XXXVI.     Syphilis  of  the  Ulna — Extensive  Loss  of  Substance 103 

XXXVII.     Periostitis    of   the   Tibia 107 

XXXVIII.     Rachitic   Bones in 

XXXIX.     Rachitic   Bones 113 

XL.     Rachitic    Bones 115 

XLI.     Sub-Periosteal  Hetnorrhage  in  Scurvy — Acute  Stage....  119 
XLII.     Extensive     Sub-Periosteal     Hemorrhage     in      Scurvy — 

Chronic    Stage 121 

XLIII.     Multiple  Exostoses  of  the  Bones  of  the  Forearm 125 

XLIV.     Osteoid  Chondroma  of  the  Femur 127 

XLV.     Cyst    of    Bone 129 

XLVI.    Archritis  of  the  Knee  Joint 133 

XLVII.    Arthritis  of  Knee  Joint— Small  Adhesion 135 

XLVIII.     Fibrous  Ankylosis  of  the  Elbow  Joint 137 

XLIX.     Bony  Ankylosis  of  the  Ankle  Joint 139 

L.     Rheumatoid  Arthritis  of  the  Wrist — Hypertrophic  Type.  l-)3 

LI.     Rheumatoid  Arthritis  of  the  Knee — Atrophic  Type I-)S 

LII.     Tubercular  Arthritis  of  the  Knee — Early  Stage 149 

LIII.     Tubercular  .Arthritis  of  the   Hip 151 

LIV.     Tubercular  Coxitis  of  the  Right  Hip — First  Stage — Child 

Four   Years   Old 153 

LV.     Tubercular  Coxitis   of  the   Right  Hip — Second   Stage — 

Bone  Involvemnt — Child  Four  Years  Old 155 

LVI.     Tubercular  Coxitis  of  the  Right  Hip — Third  Stage — Bone 

Destruction — Child   Four  Years   Old 157 

LVII.     Loose    Semi-Lunar    Cartilage 159 

LVI II.     Fracture  of  the  Right  Femur — .Antero-Posterior  View — 

Same  Case  as  Plate  LIX 163 

LIX.     Fracture  of  the  Right  Femur — Lateral  View — Same  Case 

as  Plate  LVIII 165 


—  9  — 


PLATE  PAGE 

LX.     Gun-Shot  Fracture  of  the  Lower  End  of  the  Humerus — 

Antero-Posterior  View — Same  Case  as  Plate  LXI.  .     167 
LXI.     Gun-Shot  Fracture  of  the  Lower  End  of  the  Humerus — 

Lateral  View — Same  Case  as  Plate  LX 169 

LXIL     Impacted  Fracture  of  the  Surgical  Neck  of  the  Femur — 

Clinical  Diagnosis  was  Contusion  of  Hip 171 

LXHL     Fracture  of  the  Anotomical  Xeck  of  the  Femur — Clinical 

Diagnosis  was  Contusion  of  Hip 173 

LXIV.     Fracture    of    the    Pelvic    Bones — Fracture    Line    Runs 

Through    the    Acetabulum 175 

LXV.     Fracture  of  the  Upper  End  of  the  Shaft  of  the  Femur — 
The  Fracture  Runs  Through  the  Inter-Trochanteric 

Line  of  the  Femur 177 

LXVL  Fracture  of  the  Astragalus — Clinical  Diagnosis,  Contu- 
sion of  the  Ankle \yg 

LXVn.     Fracture  of  the  Patella — Skiagram  Taken  About  Three 

Months  After  Suturing  of  the  Capsule 181 

LXVHL     Dislocation  Backwards  and  Upwards  of  Both  Bones  of 
the   Forearm — Antero-Posterior   View — Fracture  of 

the  Olecranon — Same  Case  as  Plate  LXIX 185 

LXIX.  Dislocation  Backwards  and  Upwards  of  Both  Bones  of 
the  Forearm — Lateral  View — Fracture  of  the  Ole- 
cranon— Same  Case  as  Plate  LXVHI 187 

LXX.     Dislocation   Downwards,   Forwards   and  Inward   of  the 

Head  of  the  Humerus — Old  Dislocation i8g 

LXXI.     Double    Congenital    Dislocation    of    the    Hips — Exotosis 

on  the  Shaft  of  the  Left  Femur ipr 

LXXII.     Reduced  Congenital  Dislocation  of  the  Right  Hip 193 

LXXIII.     Gun-Shot  Wound  of  the  Right  Thigh— Bullet  Lodger  in 

the   Greater   Trochanter 197 

LXXIV.     Gun-Shot  Wound   of  the  Knee — Bullet  Lodged   in   the 

Upper  End  of  the  Tibia 199 

LXXV.     Gun-Shot  Wound  of  the  Arm — Gun-Shot  Fracture  of  the 
Humerus — Antero-Posterior    View — Same    Case    as 

Plate  LXXVI 201 

LXXVI.     Gun-Shot  Wound   of   the  Arm — Gun-Shot   Fracture   of 
the  Humerus — Lateral  View — Same   Case  as   Plate 

LXXV  , 203 

LXXVII.     Gun-Shot   Wound   of   the  Left   Knee — Antero-Posterior 

View — Same  Case  as  Plate  LXXVIII 205 

LXXVIII.     Gun-Shot    Wound    of   the    Knee — Lateral    View — Same 

Case  as   Plate  LXXVII 207 


PREFACE 

The  Roentgen  Ray  is  no  longer  employed  merely  to  locate  for- 
eign bodies,  to  diagnose  fractures  and  to  render  valuable  assist- 
ance in  the  treatment  of  the  latter.  By  its  means  we  can  detect 
pathological  changes  taking  place  in  Bones  and  Joints  and  dif- 
ferentiate between  those  due  to  different  diseases.  Its  importance 
to  the  surgeon  and  the  physician  in  the  diagnosis,  prognosis  and 
treatment  of  the  pathological  conditions  of  Bones  and  Joints  is 
therefore  of  paramount  importance.  With  a  just  and  increasing 
appreciation  of  its  usefulness  in  these  cases  the  X-ray  is  made 
use  of  more  frequently,  and  it  becomes  necessary  for  the  medical 
profession  to  be  able  to  correctly  interpret  X-ray  negatives. 

This  atlas  has  been  prepared  with  the  hope  that  it  might  prove 
of  valuable  assistance  to  the  surgeon,  the  physician,  and  the  X-ray 
operator,  with  limited  experience  and  facilities  in  interpreting 
skiagrams. 

The  author  has  tried  to  be  practical  both  in  the  writing  and 
general  arrangement  of  the  work,  and,  with  the  exception  of  the 
Chapter  on  Skiagraphy,  which  was  prepared  with  the  view  of 
being  of  still  further  assistance  to  the  beginner  in  X-ray  work, 
all  theoretical  and  technical  descriptions  and  discussions  have 
been  omitted. 

The  cuts  are  correct  reproductions  of  photographic  prints  of 
X-ray  negatives  made  by  the  author,  and  have  not  been  retouched. 
They  were  carefully  selected  so  as  best  to  illustrate  the  various 
subjects  treated,  and  help  most  in  establishing  the  diagnosis  of 
abnormal  conditions  of  bone  or  joint  as  seen  on  the  X-ray  nega- 
tive under  examination.  Facing  each  cut  is  a  concise  and  ac- 
curate description  of  same,  and  throughout  the  work,  whenever 
necessary,  are  descriptive  notes. 

To  those  gentlemen  who  are  expert  in  this  field  of  medicine 
the  author  hopes  that  the  varied  collection  of  skiagrams,  especially 
those  illustrating  different  stages  of  the  changes  due  to  disease 
occurring  in  Bones  and  Joints,  may  prove  of  interest. 


The  author  is  indebted  to  the  Administrators  of  the  Charity 
Hospital  for  the  rare  opportunities  afforded  in  observation  and 
experimentation  in  this  important  and  interesting  field.  Also  to 
his  Assistants  in  the  X-Ray  Department  of  that  institution  and 
to  others  for  their  valuable  assistance  and  the  many  courtesies 
extended  to  him. 

Amedee  Granger,  M.  D 
Maison  Blanc  Building-,  New  Orleans,  La. 


INTRODUCTION 

Since  the  discovery  of  the  X-ray  by  Roentgen  in  1895,  and  its 
practical  application  to  the  diagnosis  of  fractures  and  to  the  detec- 
tion of  foreign  bodies,  its  field  of  usefulness  as  a  diagnostic  agent 
has  steadily  enlarged  with  the  improvements  in  apparatus  and 
operating  technic.  The  latest  advance,  and  I  believe  the  most  im- 
portant, is  its  use  as  a  practical  and  almost  infallible  means  of 
diagnosing  the  diseases  of  bones  and  joints. 

Without  detracting  from  the  value  of  the  X-ray  in  locating  cal- 
culi and  foreign  bodies,  in  the  diagnosis  of  affections  of  the  thor- 
acic viscera,  and  as  a  guide  to  the  proper  treatment  of  fractures, 
its  superior  advantage  to  the  surgeon  in  establishing  the  diag- 
nosis of  the  affection  and  the  extent  of  bone  and  joint  involve- 
ment before  operation,  enabling  him  to  make  a  prognosis  and  to 
select  the  proper  treatment,  becomes  at  once  apparent,  and  of 
immense  importance  to  the  patient. 

We  must  become  trained  in  the  examination  of  the  X-ray  nega- 
tive, because  no  process  of  printing  can  bring  out  all  the  grada- 
tions in  tone  that  appear  on  a  good  negative.  Nothing  must  be 
lost  even  thought  it  should  show  up  indistinctly.  Of  course,  the 
most  satisfactory  manner  of  making  this  examination  is  by  view- 
ing the  plate  in.  a  negative  illuminator  or  shadow-box  placed  in 
a  dark  or  darkened  room.  The  shadow-box  consists  of  a.  con- 
trivance in  which  plates  of  different  sizes  can  be  viewed  in  dif- 
ferent positions  and  at  different  angles  by  a  controllable  reflected 
light.  The  arrangement  is  very  simple  and  the  intensity  of  the 
light  easily  controlled  by  means  of  a  rheostat.  The  control  of 
light  is  very  important.  Without  it  the  details  in  very  thin  nega- 
tives would  be  lost.  The  light  should  be  turned  on  very  gradually, 
and  the  differences  in  tone  of  the  shadows  carefully  looked  for 
and  their  contour,  size,  etc.,  noted.  The  advantage  of  being  able 
to  examine  the  plates  at  different  angles  will  be  appreciated  by 
all  those  who  have  had  experience  in  this  line  of  work,  as  it 
often  enables  one  to  see  slight  differences  in  shadings,  denoting 
abnormalities,  which  otherwise  would  have  escaped  the  examina- 


—  14  — 

tion,  no  matter  how  minute.  If  we  have  no  sliadow-box,  the  next 
best  thing  would  be  to  replace  a  pane  of  glass  in  a  window  hav- 
ing a  good  and  clear  view  of  the  sky  by  a  piece  of  ground  glass. 
When  cxaming  an  X-ray  negative  by  this  means,  it  should  be 
placed  against  the  ground  glass  window,  if  it  is  dense,  and  held 
■  away  from  it  if  thin,  and  should  also  be  held  at  various  angles. 
Still  another  and  very  satisfactory  way  is  to  hold  a  large  piece 
of  ground  glass  in  front  of  an  incandescent  or  other  brilliant 
light  and  proceed  with  the  examination  of  the  X-ray  plate,  as  in 
the  case  of  a  ground  glass  window.  In  any  case,  the  film  side 
of  the  plate  should  be  turned  towards  the  light  and  it  should 
be  viewed  from  the  glass  side.  In  that  manner  we  examine  a 
plate  as  we  would  a  patient  with  the  fluoroscope.  The  plate  re- 
places the  fluescent  screen  with  the  image  on  it  of  a  patient, 
placed  between  the  light  or  tube  and  the  plate  or  screen,  as  the 
case  may  be.  By  so  doing  we  establish  a  more  accurate  basis  of 
comparison  between  our  skiagraphic  and  our  fluoroscopic  work. 
The  shadows  appear  on  the  screen  or  plate  as  the  parts  which 
cause  them  exist  in  the  subject ;  that  is,  what  is  seen  on  the  right 
side  of  the  plate  or  screen  is  on  the  right  side  of  the  subject, 
or  vice  versa. 

Still  another  reason  for  viewing  the  X-ray  negatives  through 
their  glass  sides  is  that  the  image,  in  photographic  prints  made 
by  exposing  to  some  light  a  sensitized  piece  of  paper  held  firmly 
against  the  film  side  of  the  X-ray  negative,  appears  as  when 
seen  through  the  glass  side  of  the  negative.  The  advantages 
from  this  constant  association  of  ideas,  and  because  we  do  not 
have  to  transpose  the  images  or  shadows,  more  than  counter- 
balance the  slight  disadvantages  of  looking  at  the  shadow  on  the 
film  through  the  glass  of  the  plate. 

Interpret.\tion.  Before  one  is  competent  correctly  to  inter- 
pret an  X-ray  plate,  he  must  know  and  tlioroughly  appreciate : 

First.    That  an  X-ray  negative  is  a  shadowgraph. 

Second.  The  necessity  of  being  familiar  with  the  appearance 
of  radiographs  of  the  normal  anatomy. 

Third.  To  be  familiar  with  the  patholog)'  of  bones  and  joints. 
This  is  important  because,  as  will  be  shown  throughout  the  dis- 
cussion of  the  various  diseases,  the  abnormal  X-ray  shadows  are 
always  easily  accounted  for  by  definite  pathological  changes  in 
the  bone  or  joint. 

Fourth.  The  importance  of  the  relative  positions  of  the  tube, 
the  patient  and  the  plate  to  each  other. 

I.  The  X-ray  picture  is  a  shadowgraph.  The  X-rays  that 
reach  the  plate  afifect  the  film  as  do  ordinary  light  rays.  When 
we  interpose  between  X-rays  and  the  photographic  plates  objects 


—  15  — 

of  different  atomic  weight,  the  heavier  substances  prevent  the 
passage  of  the  rays  more  than  the  light  ones,  and  the  film  being 
unequally  acted  upon,  shows  not  an  image,  but  shadows  of  vari- 
ous tones.  Precisely  the  same  thing  occurs  when  we  skiagraph 
any  part  of  the  human  body,  composed  as  it  is  of  structures  of 
varying  densities.  The  bones  appear  white  on  the  plates,  the 
other  tissues  vary  in  tone  from  light  to  dark  gray.  Therefore,  a 
good  negative  would  show  not  only  foreign  bodies  and  gross 
pathological  lesions  of  the  skeleton,  such  as  fractures,  disloca- 
tions, but  would  also  show  changes  in  bone  structure,  the  pres- 
ence of  callous,  of  effusions  and  exudates,  tubercular  involve- 
ments, etc. 

2.  A  thorough  and  minute  knowledge  of  the  appearance  of 
the  human  anatomy,  seen  with  the  X-rays,  is  of  paramount  im- 
portance. Dr.  E.  W.  Shenton,  in  an  admirable  article  in  the 
Physician  and  Surgeon,  says:  "The  surgeon  who  relies  on  his 
anatomical  knowledge  to  translate  a  radiographic  appearance  will 
find  that  he  depends  upon  a  broken  reed."  Possibly  the  most 
striking  instance  of  this  is  found  in  the  appearance  of  a  normal 
knee-joint.  We  are  immediately  struck  by  the  high  position  of 
the  patella,  accustomed  to  seeing  it  pictured  in  all  text-books  on 
anatomy  as  covering  the  joint.  The  epiphyseal  line  in  children 
and  young  adults  could  be  mistaken  for  fractures.  The  appear- 
ance of  the  pelvis  of  a  young  child,  with  the  apparent  separation 
between  the  pelvic  bones,  and  the  absence  of  the  femoral  head, 
all  due  to  unossified  cartilage,  is  striking.  Another  source  of 
error  could  be  made  in  the  acromio-clavicular  articulation.  Un- 
less the  normal  appearance  of  joints  and  of  bone  textures  of 
individuals,  from  children  to  adult  hfe,  is  known,  the  diagnosis 
of  pathological  conditions  becomes  impossible. 

3.  We  must  know  what  changes  in  the  structures  of  bones 
and  joints  the  different  diseases  produce.  The  general  course 
of  the  affection,  its  predilection  for  certain  bones  or  joints  and 
for  particular  parts  or  structures  of  these. 

For  example,  new  bone  formations,  callous,  cartilage  before 
ossification,  throw  a  shadow  which  is  only  slightly  more  dense 
than  that  of  the  surrounding  soft  parts,  but  becomes  denser  as 
ossification  takes  place.  In  such  diseases  as  rickets,  where  proper 
calcification  does  not  take  place,  tuberculosis,  where  we  find 
absorption  of  the  lime  salts  and  a  rarifying  osteitis,  the  bone 
shadow  becomes  paler  than  normal. 

In  syphilis,  around  bone  abscesses,  the  walls  of  circumscribed 
osteomyelitis,  we  find  a  denser  bone  shadow,  due  to  bone  sclerosis. 

Effusions  and  extravasation  cause  shadows,  the  density  of  which 
depends  upon  the  nature  of  the  effusions  or  extravasation. 


—  i6  — 

Hemorrhages,  producing  blood  cysts  or  pigmented  areas  of  ex- 
travasated  blood,  so  commonly  seen  in  sarcoma,  show  as  irregular 
shadows,  which  are  of  considerable  diagnostic  importance. 

4.  The  importance  of  the  relative  position  of  tube,  patient 
and  plate  to  each  other.  The  X-rays  are  given  off  as  a  cone  of 
light  from  the  target  or  anticathode  of  the  tube,  the  most  central 
ray,  or  ray  of  normal  incidence,  produces  a  perfect  shadow,  that 
is,  one  without  distortion ;  the  farther  we  get  away  from  this  ray, 
the  more  oblique  the  ray  employed  becomes,  the  greater  the  dis- 
tortion of  the  shadow  produced  by  them.  From  the  above,  it 
becomes  obvious  that  the  normal  ray  should  be  known,  and  that 
it  should  be  made  to  pass  through  the  centre  of  the  plate  or  part 
being  examined.  Besides,  we  must  also  know  at  what  distance 
the  tube  was  when  the  skiagraphs  were  taken,  as  the  closer  the 
tube  to  the  plate,  the  greater  the  shadow  produced,  and  this 
enlarged  shadow,  although  free  from  distortion,  may  become  the 
source  of  error.  The  part  should  always  lie  as  near  to  the  plate 
as  possible,  because,  first,  the  farther  away  from  the  plate,  the 
greater  the  shadow ;  second,  the  greater  the  angle  it  forms  with 
the  plate,  the  more  distorted  the  shadow.  For  that  reason,  the 
hip  and  shoulder  present  unusual  difficulties.  No  comparison 
of  value  could  be  made  between  the  skiagraph  of  a  sound  hip 
taken  while  rotated  inwards  and  that  of  an  affected  hip  rotated 
outwards. 

Dr.  John  Hall  Edwards,  in  a  highly  interesting  article  in  the 
September,  1906,  number  of  the  Archives  of  the  Roentgen  Rays, 
says:  "As  long  as  surgeons  are  content  to  accept  the  evidence 
of  a  radiograph  taken  under  unknown  conditions  and  by  an  un- 
skilled operator,  so  long  will  mistakes  be  made  and  the  way  kept 
open  for  fraud  and  quackery. 

"The  value  of  the  interpretation  of  the  radiograph  depends 
entirely  upon  the  knowledge  and  experience  of  the  expert  who 
is  asked  to  give  an  opinion,  and  a  good  opinion  cannot  be  formed 
from  viewing  a  radiograph  produced  from  a  Crooke's  tube  held 
in  an  unknown  position.  A  large  amount  of  distortion  is  easily 
detected  by  anyone  used  to  the  examination  of  X-ray  pictures, 
but  a  small  amount  is  frequently  difficult  to  recognize,  even  by 
an  expert." 


SKIAGRAPHY 

Skiagraphy  is  the  art  of  taking  images  of  the  different  parts 
•of  the  human  body  on  sensitized  plates  by  means  of  the  X-ray. 
It  is  of  course  impossible  in  a  book  of  the  nature  of  this  one  to 
enter  into  descriptions  of  the  apparatus  necessary  for  the  pro- 
duction of  the  X-ray.  Several  excellent  text-books  treating  of 
these  subjects  in  a  thorough  and  scientific  manner  have  been 
published,  and  the  reader  desiring  this  information  is  referred 
to  them.  In  this  chapter  only  a  few  practical  hints  are  given, 
and  it  was  written  in  the  hope  that  it  might  prove  useful  to  the 
inexperienced  X-ray  operator. 

WTien  making  skiagraphs  the  X-ray  plate,  enclosed  in  its  en- 
velopes of  black  and  orange  paper,  must  be  placed  in  as  close 
contact  with  the  part  to  be  skiagraphed  as  possible  and  with  the 
film  side  of  the  plate  turned  towards  it.  Under  the  X-ray  plate 
place  a  sheet  of  lead  the  size  of  the  plate,  this  will  prevent  the 
fogging  of  the  X-ray  plate,  which  might  take  place  if  any 
secondary  rays  are  given  off  by  its  glass  surface.  These  sec- 
ondary rays  are  produced  whenever  any  X-rays  which  have  not 
been  absorbed  by  the  tissues  and  by  the  sensitized  film  reach  the 
glass  surface  of  the  X-ray  plate. 

Whenever  possible,  the  part  to  be  examined  should  be  skia- 
graphed lying  in  two  positions,  which  are  at  right  angles  to 
each  other.  This  is  of  great  importance  not  only  in  locating 
foreign  bodies  and  pathological  conditions,  but  also  in  showing 
the  extent  of  the  latter,  or  the  results  of  treatment  or  operation. 
No  exception  to  this  rule  should  be  made  when  skiagraphing 
the  hand.  I  know  that  the  current  practice  is  to  take  a  palmar, 
then  a  dorsal  view.  \'ery  little  additional  information  is  gained 
by  the  second  view. 

Remember  that  the  X-rays  are  given  off  as  a  cone  of  light 
from  a  point  on  the  anticathode  or  target  of  the  X-ray  tube. 
This  part  of  the  anticathode,  which  can  be  recognized  as  a  small, 
roughened,  or  indented  spot  on  it,  should  be  placed  over  the 
center  of  the  part  to  be  skiagraphed  and  over  the  center  of  the 
X-ray  plate.  When  making  use  of  a  compression  diaphragm  the 
X-ray  tube  should  be  focussed;  that  is,  the  point  of  emission  of 
the  rays  placed  over  the  center  of  the  upper  opening  of  the 
diaphragh.  The  use  of  a  diaphragm  will  give  much  finer  and 
clearer  negatives,  because  the  secondary  rays,  given  off  from  the 
surface  of  the  X-ray  tube,  which  blur  the  image  by  the  produc- 
tion on  the  sensitized  plate  of  secondary  and  indistinct  shadows, 


—  i8  — 

are  not  permitted  to  reach  the  plate.  In  some  cases,  for  instance. 
when  making  skiagraphs  of  the  hip,  spine,  or  pelvis,  and  of  the 
renal,  hepatic,  and  vesical  regions,  when  looking  for  calculi,  a 
compression  diaphragm  is  an  absolute  necessity. 

Therefore  the  best  results  are  only  obtainable  when  we  can 
accurately  focus  the  ray  of  normal  incidence,  i.  c.  the  normal  or 
central  ray,  cut  out  the  secondary  X-rays,  and,  as  far  as  possible, 
prevent  the  passage  of  the  inverse  discharge  through  the  X-ray 
tube.  (See  text-books  on  Radiology,  also  description  of  author's 
Radiologic  Frame.) 

Always  bear  in  mind  that  to  produce  an  even  illumination  of 
an  X-ray  plate,  the  target — the  point  of  emission  of  the  cone  of 
X-ray  light — must  be  placed  over  its  center  and  at  a  distance 
from  it  of  not  less  than  twice  that  of  its  longest  diameter.  For 
example,  when  using  an  X-ray  plate  ii  x  14  ins.,  if  the  antica- 
thode  of  the  tube  is  not  placed  over  its  center  and  at  a  distance 
of  not  less  than  28  ins.,  the  shadows  thrown  on  the  plate  although 
clear  and  distinct  in  the  center  would  be  indistinct  at  the  edges 
of  the  plate.  Moreover,  if  the  target  was  not  well  over  the  center 
of  the  plate  the  shadows  would  be  distorted,  and  the  more  so  the 
greater  the  obliquity  of  the  rays  producing  them.  Note  that  we 
always  mention  the  distance  from  the  anticathode  to  the  plate 
and  not  from  the  glass  surface  of  the  X-ray  tube  to  the  plate. 
The  size  of  X-ray  tubes  vary  from  5  ins.  to  9  ins.  in  diameter, 
but  the  X-rays  are  always  given  off  from  a  point  on  the  anti- 
cathode,  and  if  one  operator  using  a  5-in.  diameter  tube  stated 
that  he  made  a  skiagraph  at  a  distance  of  20  ins.  from  the  plate — 
measuring  from  glass  surface  of  tube  to  plate — another  observer 
with  exactly  the  same  installation  and  under  the  same  conditions, 
but  using  a  9-in.  diameter  tube,  would  not  duplicate  the  results  in 
the  same  time,  because  the  target  of  his  tube  would  be  2  ins. 
farther  off  from  the  plate — ;'.  c.  in  the  first  instance  the  target 
would  be  at  22>^  ins.  and  the  second  24>4  ins.  from  the  plate. 

A  verv  important  factor  in  all  skiagraphic  work,  the  one  factor 
which  gives  more  trouble  to  the  inexperienced  operator  than  any 
other,  is  the  length  of  time  that  the  X-ray  exposure  should  last 
in  order  to  obtain  a  good  skiagraph.    This  depends  upon 

First.  The  intensity  of  the  X-ray  light,  which  depends  upon 
the  energy  of  the  current  which  activates  the  X-ray  tube.  This 
will  vary  with  the  size  and  style  of  the  generating  apparatus, 
whether  static  machine,  induction  coil,  X-ray  transformers  or 
generators.  If  an  induction  coil  upon  the  style  of  interrupter 
and  the  amount  of  current  in  the  primary. 

Second.  The  penetration  of  the  X-rays.  This  depends  upon 
the  state  of  vacuum  of  the  X-rav  tube. 


—  19  — 

Third.     The  distance  from  anticathode  to  plate. 

Fourth.  The  subject  to  be  skiagraphed,  /.  c,  the  nature  of  the 
part,  the  age,  weight,  size  and  sex  of  the  patient.  Also  the  con- 
dition of  the  part  and  the  presence  of  dressing,  splints,  etc. 

It  is  at  once  apparent  that  if  all  these  factors  are  varying  con- 
tinually it  is  impossible  to  do  anything  but  guesswork,  and 
the  correct  timing  of  an  X-ray  exposure  becomes  a  physical 
impossibility.  It  is  necssary  therefore  to  render  all  these  factors 
constant  as  much  as  possible.  Fortunately  for  all  practical  pur- 
poses this  is  possible  with  all  except  the  constantly  changing 
factor  of  the  subject,  here  the  experience  and  observation  of  the 
operator  alone  will  overcome  the  difficulty.  In  our  Department 
at  the  Charity  Hospital  w'here,  in  the  last  four  years,  we  have 
made  over  3,500  skiagraphs,  we  have  adopted  the  following  plan 
with  very  satisfactory  results,  v'lz. :  We  make  use  of  a  coil,  be- 
cause it  is  not  influenced  by  atmospheric  and  temperature  condi- 
tions as  is  the  case  with  the  static  machine,  and  because  the  out- 
put of  current  is  so  much  greater  than  with  the  latter  type  of 
apparatus.  The  coil,  interrupter  and  rheostat  are  regulated  to 
give  a  certain  output  through  the  secondary  terminals.  The 
auto-regulable  X-ray  tubes  w"hich  we  employ  are  regulated  to 
furnish  when  activated  by  the  coil  a  ray  of  medium  penetration. 
We  always  make  use  of  a  Roentgen  ammeter  in  the  secondary 
circuit  with  the  X-ray  tube.  The  reading  on  the  scale  of  this 
instrument  will  indicate  at  once  any  change  in  the  vacuum  of 
the  X-ray  tube,  hence  in  the  penetrating  power  of  the  ra^'s  given 
off  by  it,  provided  that  the  first  factor,  the  energizing  current 
produced  bv  the  coil,  has  remained  constant.  The  reading  of  the 
meter  will  be  greater  when  the  .vacuum  of  the  tube  is  lowered, 
and  less  when  the  vacuum  of  the  tube  is  higher.  Within  certain 
limits  the  higher  the  vacuum  of  the  tube  the  more  penetrating 
the  X-rays  produced  by  it,  the  lower  the  vacuum  the  less  pene- 
trating the  rays. 

Besides  any  sudden  and  marked  variation  in  the  reading  of  the 
Roentgen  ammeter — the  needle  dropping  to  o,  or  just  as  sud- 
denly jumping  up  3  or  more  ma.,  is  an  indication  that  the  X-ray 
tube  is  very  overtaxed  and  is  either  about  to  puncture  or  to  have 
its  vacuum  lowered  to  a  point  which  renders  it  useless  for  future 
work.  The  warning  should  be  heeded  and  the  current  turned  off 
at  once. 

In  the  Department  an  assistant  remains  at  the  switchboard  and 
keeps  a  watchful  eye  on  the  Roentgen  ammeter,  especially  when 
doing  work  which  we  know  will  put  the  X-ray  tube  on  more  or 
less  of  a  strain. 

The  two  factors,  the  current  output  and  the  degree  of  vacuum 


of  tlie  tube,  can  for  all  practical  purposes  be  regulated  and 
made  constant.  This  having  been  done  we  render  the  third 
factor,  that  of  the  distance  from  anticathode  to  plate,  constant 
by  always  working  at  stated  distances.  We  do  practically  all  of 
our  work  in  the  following  distances : — 22  ins.,  25  ins.  and  28  ins., 
respectively.  We  employ  the  smaller  distance  when  making  use 
of  compression,  the  middle  one  for  most  of  the  work,  and  the 
greater  one  when  making  exposures  on  X-ray  plates  11x14  '"S. 
in  size. 

Since  the  action  of  the  X-rays  on  the  sensitized  plate  is  in- 
versely as  the  square  of  the  ratio  of  the  distance  then,  where 
we  would  expose,  say  one  time  at  a  distance  of  22  ins.,  we  would 
have  to  expose  one  and  a  third  times  as  long  at  25  ins.,  and  one 
and  two-third  times  as  long  at  28  ins.  to  obtain  the  same  result. 
This  ratio,  one  time  for  22  ins.,  one  and  a  third  times  for  25  ins., 
and  one  and  two-third  times  for  28  ins.,  can  be  easily  remembered, 
and  it  gives  us  three  convenient  and  practical  distances  and  at 
the  same  time  makes  the  third  factor,  that  of  distance,  constant 
also. 

To  assist  in  the  practical  working  out  of  the  last  factor,  that 
of  the  subject,  I  have  prepared  the  following  table  of  comparative 
exposures  for  the  diiiferent  parts  of  the  adult  body  of  medium 
size  and  weight. 

TABLE  OF  COMTARATIVE  EXPOSURES. 

Ankle    2  times  Neck     8  times 

Arm    3       "  Pelvis    12 

Elbow    3       "  Shoulder    4]^  " 

Foot   2;/"  Skull    7       " 

Forearm    2       "  Spine    12      " 

Hip    11       "  Teeth    6       " 

Kidney   6      "  Thigh    7      " 

Knee    6      "  Thorax    6      " 

Leg    5       "  Wrist  and  hand  1  time 

This  table  has  proved  of  inestimable  value  to  us  during  the 
past  three  years. 

Proceed  in  the  following  manner,  after  installing  your  outfit, 
if  a  new  one,  or  after  cleaning  and  overhauling  it,  if  one  already 
in  use,  regulate  it  so  as  to  give  a  certain  discharge  at  the  sec- 
ondary terminals.  When  this  has  been  done  connect  up  your 
X-ray  tube  to  these  terminals,  with  a  Roentgen  ammeter  in 
circuit,  and  take  a  skiagraph  of  a  normal  hand  and  wrist 
of  a  medium-sized  adult  at  a  distance  of  22  ins.  Note  care- 
fully the  amount  of  current  in  the  primary  of  the  inductor, 
as  shown  by  reading  the  ammeter  on  the  switchboard,  the  read- 


ing  of  the  Roentgen  ammeter,  and  the  degree  of  penetration  of 
the  rays  emitted  by  the  tube.  This  last  information  is  obtained 
by  means  of  a  penetrameter  scale.  We  make  use  of  the  Benoist. 
This  data  once  obtained  is  of  jKJsitive  and  practical  value  as  long 
as  the  conditions  remain  the  same.  Any  change  in  these  will  be 
at  once  indicated  b)-  a  change  in  the  reading  of  one  or  both  am- 
meters, and  will,  of  course,  require  either  readjusting  of  the 
apparatus  or  correction  of  the  time  of  the  exposure.  With  a 
good  apparatus  and  auto-regulable  X-ray  tubes  this  will  only 
have  to  be  done  at  long  intervals. 

Repeat  the  experiment  of  taking  a  skiagraph  of  the  hand  and 
wrist  until  you  find  the  correct  exposure  necessary  to  give  you 
a  good  and  well  contrasted  negative.  You  are  now  in  a  position 
to  make  skiagraphs  of  any  part  of  the  body  with  every  chance 
of  success. 

EXAMPLE. 

Let  us  say  that  it  took  15  seconds  to  make  a  good  negative  of 
the  hand  and  wrist  at  22  ins.  distance.  Then  at  25  ins.  distance  it 
would  require  an  e.xposure  of  20  seconds  (15"  x  i  1-3)  ;  and  at 
28  ins.  distance  it  would  require  an  exposure  of  25  seconds 
(15"  X  I  2-3).  To  make  a  good  skiagraph  of  an  elbow  we  find 
by  consulting  the  Table  of  Comparative  Exposure  that  it  takes 
three  times  as  long;  then  45  seconds  (i5"x3)  exposure  would 
give  a  good  skiagraph  of  the  elbow  joint  at  a  distance  of  22  ins. ; 
60  seconds  (20"  x  3)  at  a  distance  of  25  ins.;  and  75  seconds 
(25"  X  3)  at  a  distance  of  28  ins. 

As  already  stated,  the  duration  of  the  exposure  will  have  to 
var}'  from  the  above,  depending  upon  the  age,  size,  and  weight  of 
the  patient.  Here  no  set  rule  can  be  suggested,  experience  and 
observation  alone  will  guide  the  operator. 

It  is  often  necessary  to  make  skiagraphs  of  cases  of  fractures 
and  dislocations  through  dressings  and  splints ;  in  such  cases  ex- 
pose longer  than  what  the  normal  exposure  for  the  affected  part 
would  be,  and  be  guided  by  the  quantity  and  kind  of  splint  and 
dressings  employed.  No  satisfactory  skiagraphs  of  bones  and 
joints  affected  by  disease  can  be  made  through  dressings  or 
splints.  In  this  class  of  cases,  where  we  are  looking  for  devia- 
tions from  the  normal  bone  or  joint  shadows,  the  shadows  pro- 
duced by  the  dressings  or  splints  would  be  very  troublesome  and 
misleading. 

In  the  following  pages  we  describe  an  apparatus  which  we 
have  devised  after  long  continued  observation  and  experimenta- 
tion. We  believe  that  it  will  prove  of  valuable  assistance  to  the 
X-ray  worker,  especially  in  the  field  of  skiagraphy. 


PLATE  I. 

THE  author's  X-ray  laboratory. 

Showing  the  Author's  sliding  Universal  X-ray  frame  in  position  to  do 
radiographic  or  radiotherapeutic  work,  with  the  patient  lying  on  the 
operating  table.  The  X-ray  tube  is  clamped  inside  of  the  box,  which  is 
lined  with  X-ray  proof  material.  This  box  is  also  provided  with  a  lead 
glass  window,  through  which  the  operator  can  observe  the  functioning 
of  the  tube.  The  tube  containing  bo.x  can  be  placed  over  any  given  point 
of  the  operating  table  by  causing  the  whole  frame  to  slide  between  its 
tracks  from  end  to  end  of  the  table,  and  by  moving  the  cradle  holder  of 
the  box  on  the  hinged  frame  overlooking  the  table  from  side  to  side  of 
the  latter.  The  vertcal  movement,  i.  e.,  the  movement  to  and  from  the 
table  is  obtained  by  turning  the  pilot  wheel  placed  at  the  right  hand  of 
of  the  operator  and  on  his  side  of  the  operating  table.  It  becomes  self- 
evident  that  this  apparatus  not  only  insures  adequate  protection  to  the 
operator  but  permits  him  to  accomplish  his  work  from  his  side  of  the 
table  without  having  to  reach  over  or  beyond  his  patient,  and  with  the 
greatest  accuracy,  speed  and  convenience. 


PLATE  I. 


PLATE  II. 


THE    ACTHOK  S     X-RAY     LAFORATORV. 


Showing  the  Author's  sliding  Universal  X-ray  frame  in  position  for 
fluoroscopic  work,  or  radiography  or  radiotheraphy,  with  the  patient  in 
the  sitting  posture,  .-^s  the  fluroescent  screen  and  plate  holders  are  inter- 
changeable, either  can  be  used  without  disturbing  the  patient  or  the 
remainder  of  the  apparatus.  The  opening  in  the  front  of  the  tube  hrilding 
bo.x  is  fitted  with  an  X-ray  proof  iris  diaphrani,  and  on  the  outside  of  tli:s 
opening  is  a  channel  holder  which  receives  various  attachments  used  for 
special  work,  such  as  orthodiagraphic  tracings,  localization,  etc.  The 
screen  and  the  plate  holder  are  attached  to  the  carriage  which  supports 
the  tube  holding  box.  and  it  follows  that  every  movement  imparted  to 
them  causes  a  similar  movement  of  the  tube,  and  vice  versa.  The 
operating  table  is  shown  op«n,  with  a  subject  seated  upon  a  stool  ready 
to  be  tluoroscoped.  This  stool  has  a  revolving  seat,  which  can  be  lowered 
or  raised  as  required.  A  lateral  movement  is  imparted  to  the  screen  and 
tube  by  taking  hold  of  the  screen  holder  and  causing  the  whole  frame  to 
slide  on  its  tracks :  a  vertical  movement  by  turning  the  pilot  wheel  to  the 
right  or  left.  Reaching  overhead,  the  lights  in  the  room  are  controlled 
by  appropriate  switches,  reaching  back,  the  current  passing  through  the 
tube  is  controlled  by  a  suitable  switchboard  table.  All  of  this  is  done  by 
the  operator  from  one  stand,  with  the  greatest  ease  and  convenience,  in 
a  minimrm  of  time  ami  without  having  to  reach  to  the  side  or  beyond 
the  patient. 


PLATE  II. 


XOR^IAL  JOINTS. 

Appreciating  the  immense  advantage  of  always  having  handy 
for  comparison  a  set  of  normal  skiagraphs  when  studying  ab- 
normal ones,  especially  those  of  the  different  joints,  we  have  pre- 
pared this  chapter,  trusting  that  it  will  prove  of  real  help  to  the 
reader. 

In  it  are  only  described  the  normal  adult  joints.  There  are 
several  atlases  of  normal  skiagraphy,  which  give  skiagrams  of 
normal  joints  and  bones  from  childhood  to  adult  life. 

The  period  at  Avhich  ossification  takes  place,  and  hence  the 
shadows  depending  upon  same,  vary  so  much,  even  in  children 
of  the  same  age,  that  we  have  found  it  best  and  most  practical 
whenever  in  doubt  when  examining  skiagraphs  in  which  the 
pathological  changes  were  not  well  marked  to  compare  the  doubt- 
ful negative  with  one  made  from  the  corresponding  healthy  part 
of  the  same  patient. 

For  obvious  reasons  we  have  inserted  this  chapter  in  this  part 
of  the  work,  before  those  in  which  pathological  conditions  are 
described. 


—  28  — 


PLATE  III. 

NOKMAI,    SHori-IiER    JOINT — AXTERU-rOSTERIOR    POSITION. 

Note  the  position  of  the  head  of  tlie  hiiinenis  with  reference  to  the 
glenoid  cavity. 

The  articular  surface  of  the  head  of  the  luinierus,  its  anotoniical  neck, 
and  the  bicipital  groove  show  plainly. 

The  neck  and  spine  of  the  scapula,  the  glenoid  cavity,  the  acromion  and 
coracoid  process  can  be  easily  made  out. 

Notice  particularly  the  apparent  separation  at  the  acroniio-clavicular 
articulation 


PLATE  III. 


—  30 


PLATE  IV. 

NORMAL     SHOULDER     JOINT — POSTERIOR-ANTERIOR     VIEW — HEAD     OF     HUMERI'S 
ROTATED    OUTWARDS. 

As  in  Plate  III,  ihe  articular  surface  of  the  head  of  the  humerus,  its 
anotoniical  neck,  the  bicipital  groove,  the  glenoid  cavity,  the  neck  and 
spine  of  the  scapula,  acromion  and  coracoid  processes  all  show  up  very 
distinctly.  The  apparent  separation  of  the  acromio-clavicular  articulation 
is  not  so  noticeable. 


PLATE  IV. 


32  — 


PLATE  V. 

NORMAL     EI-BOW     JOINT — AXTERO-POSTERIOR    VIEW — FOREARM     IN     SVPINATION. 

The  humerus  articulates  with  the  uhia  and  radius,  and  the  head  of  the 
radius  articulates  with  the  lesser  sigmoid  cavity  of  the  ulna. 

We  see  distinctly  the  e.xternal  and  internal  condyles,  the  olecranon  fossa, 
the  trochlear  and  the  radial  head  of  the  humerus ;  the  olecranon  and 
coronoid  processes  of  the  ulna;  the  head,  neck  and  bicipital  tuberosity  of 
the  radius. 


PLATE  V. 


—  34- 


PLATE  VI. 

NORMAL    ELBOW    JOINT — LATER.\L    VIEW — IXTERXAL    CO^•D^XE    LYING    ON     THE 

X-RAY     PLATE — THE     FOREARM      MIDWAY     BETWEEX      PRONATION      AND 

SUPINATION,     ITS     ULNA     SURFACE    LYING    ON     THE    PLATE, 

THE   THUMB  LOOKING    UP. 

The  trochlear  surface  of  the  humerus  articulates  with  the  greater  sig- 
moid cavity  of  the  ulna,  and  the  radial  head  of  the  humerus  articulates 
with  the  head  of  the  radius. 

The  olecranon  and  coronoid  processes,  and  the  greater  sigmoid  cavity 
of  the  ulna,  and  the  head  and  neck  of  the  radius,  are  distinctly  visible. 

The  radial  head  of  the  huraerrfs  and  the  head  of  the  radius  are  larger 
and  their  contour  not  so  sharp,  because  they  were  lying  farther  from  the 
X-ray  plate  than  the  ulna  during  the  exposure. 


PLATE  VI. 


-36 


PLATE  VII. 

NORMAL     WRIST    JOIXT — PALMAR     VIEW. 

The  sigmoid  cavity  of  the  radius  receives  the  head  of  the  ulna. 

The  radius  articulates  with  the  scaplioid  and  the  semi-kui?r. 

The  cuneiform  is  separated  from  tlie  lower  end  of  the  uhia  by  tlie 
triangular  ligament,  which  throws  no  shadow  on  the  skiagrauL 

The  first  row  of  carpal  bones  seen  on  the  skiagram  from  without  in- 
wards are  the  scaphoid,  the  semi-lunar,  the  cuneiform  and  the  pisiform. 
The  last  bone  can  be  distinguished  as  an  almost  round  shadow  overlapping 
the  inner  half  of  the  cuncifonn. 

The  lower  row  of  carpal  bones  proceeding  from  the  nieta-cariKil  bone 
of  the  thumb  inwards  are  the  trapezium,  the  trapezoid,  the  os  m.^gnunl, 
and  the  unciform. 

The  unciform  or  hook-like  process  of  he  unciform  bono,  tlie  small  sesa- 
moid bone  of  the  thumb,  and  the  styloid  process  can  all  be  plainly  seen. 


PLATE  VII. 


38- 


PLATE  VIII. 

NORMAL    HAND — PALMAR    VIEW. 

Note  the  shape  and  the  structural  detail  of  the  metacarpal  bones  and 
of  the  phalanges. 

Note,  also,  the  articulation  of  the  varicms  bones  composing  the  hand. 
The  sesamoid  bone  of  the  thumb  shows  well. 


PLATE  VIII. 


—  40  — 


PLATE  IX. 

NORMAL     SACRO-LVMBAR    AND    SACRO-ILIAC    JOINTS — DORSAL    POSITIOX. 

The  sacrum  articulates  above  with  the  last  lumbar,  and  on  either  side 
with  the  ilia. 

The  sacral  spines  and  tlie  posterior  sacral  foramen  can  be  distinctly 
seen. 

At  the  lower  part  of  the  skiagram  the  articulation  between  the  sacrum 
and  the  coccyx  can  be  seen,  and  just  above  this  the  light  shadow,  partially 
surrounded  by  a  darker  border,  is  the  posterior  median  sacral  groove. 


PLATE   IX. 


—  42  — 


NORMAL    HIP    JOINT — DORSAL    POSITION". 

The  head  of  the  femur  articulates  with  the  acetabuhim. 

The  obturater  foramen,  the  anotomical  neck  of  the  femur,  its  surgical 
neck,  its  greater  and  lesser  trochanters,  the  intertrochanteric  line,  are  all 
plainly  visible. 

At  the  upper  extremity  of  the  intertrochanteric  line,  at  a  point  where 
the  shadow  of  the  neck  of  the  femur  meets  that  of  the  shaft,  a  V-shaped 
dark  line  indicates  the  position  of  the  digtal  fossa.  Above  the  outer 
margin  of  the  acetabulum  is  the  groove  for  the  tendon  of  the;  rectus 
muscle. 

Note  particularly  the  angle  formed  by  the  head  and  the  neck  of  the 
femur  with  the  shaft  of  that  bone. 


PLATE  X. 


—  44  — 


PLATE  XI. 

NORMAL    KNEE    JOINT — ANTEROPOSTERIOR   VIEW. 

The  clear  space  between  the  femur  and  the  tibia  is  due  to  the  fact  that 
the  interarticular  cartilage  does  not  produce  a  shadow  on  the  X-ray  plate, 
which  can  be  distinguished  from  that  of  the  surrounding  soft  parts. 

The  shadow  of  the  patella  can  be  plainly  seen,  and  shows  that  bone 
lying  over  the  lower  extremity  of  the  femur  with  only  a  very  small  part 
of  its  lower  end  extending  over  the  interarticular  space. 

The  spine  of  the  tibia,  the  epiphyseal  line  running  horizontally  across 
its  upper  end,  and  the  head  of  the  styloid  process  of  the  fibula,  are  all 
visible. 


PLATE  XI. 


■46- 


PLATE  XII. 

NORMAL     KNEE    JOINT — LATERAL     VIEW — THE     LEG     LYING    ON     ITS     EXTERNAL 
SURFACE. 

The  patella  is  seen  in  its  high  position,  lying  over  the  lower  end  of 
the  femur. 

The  external  condyle  of  the  femur,  which  was  lying  closest  to  the  X-ray 
plate  during  the  e.xposure,  is  easily  recognized  as  the  smaller,  denser  and 
more  distinct  .shadow. 

The  head  and  styloid  process  of  the  fibula  can  be  seen  in  the  lower 
part  of  the  skiagram. 

The  spjne  of  the  tibia  is  also  visible. 

Note  particularly  the  clear  space  lying  between  the  lower  end  of  the 
patella,  and  the  lower  end  of  the  femur  and  the  upper  end  of  the  tibia.      • 


PLATE   XII. 


-48- 


PL.XTE  XI 11. 

NORMAL   AXKI.E  JOINT — LATERAL  VIEW — FRACTURE  OF   THE  LOWER  END   OF  THE 
FIBULA. 

The  bone  structure  and  the  articular  surfaces  and  facets  show  with 
remarkable  clearness. 

The  astragahis  articulates  with  the  tibia  and  tibuLi  above,  with  the  os 
calcis  below,  and  with  the  scaphoid  in  front. 

Its  head,  neck  and  body  can  be  plainly  made  out. 

The  OS  calcis  articulates  with  the  astragalus  above  and  with  the  cuboid 
in  front.  Its  tuberosity,  grooves  and  articular  facets,  and  its  rougli  lower 
posterior  surface  for  the  attachment  of  the  tcndo  Achilhs,  all  show  dis- 
tinctly. 

The  deep  groove  on  the  inferior  surface  of  the  cuboid  bone,  which 
lodges  the  tendon  of  the  Peroncus  longus,  can  also  be  seen. 


PLATE  XIJJ. 


—  so  — 


PLATE  XIV. 

NORMAL  rnOT — PLANTAR  VIEW. 

The  cuboid  articulates  with  the  os  calcis  behind,  with  the  external 
cuneiform  on  the  inner  side,  and  with  the  4th  and  5th  metatarsal  bones 
in  front. 

The  scaphoid  articulates  with  the  astragalus  behind  and  the  three  cunei- 
form bones  in  front. 

The  internal  cuneiform  articulates  with  the  metacarpal  bone  of  tlie  big 
toe,  the  middle  cuneiform  and  the  scaphoid. 

The  external  cuneiform  is  hidden  by  the  middle  cuneiform  and  by  the 
cuboid,  but  its  rectangular  shadow,  articulating  with  the  cuboid,  the 
scaphoid,  the  middle  cuneiform,  and  the  2d,  3d  and  4th  metatarsal  bones, 
can  be  distinctly  made  out. 

Note  the  structure  and  the  articulation  of  the  metatarsal  bones  and 
phalanges. 


PLATE  XIV. 


—  53^ 


PART  II. 
DISEASES  OF  BONES  AND  JOINTS. 


OSTEOMYELITIS. 

Osteomyelitis  usually  affects  the  shaft  of  one  of  the  long  bones, 
it  may  be  in  close  proximity  to  the  joint,  but  rarely  involves  the 
latter,  except  secondarily  in  cases  of  long  standing.  It  is  recog- 
nized on  the  radiogram  by  the  lighter  area  of  bone  and  marrow 
rarefaction,  the  surrounding  darker  areas  of  bone  condensation 
and  in  some  cases  the  presence  of  sequestra  (Plate  XVI) 

The  afifection  causes  a  softening  of  the  marrow  and  a  suppura- 
ative  osteitis,  which  in  some  cases  becomes  circumscribed  by  a 
process  of  osteosclerosis.  The  periosteum  is  usually  swollen  and 
oedematous  (Plate  XV). 

In  other  cases  the  medullary  cavity  becomes  involved  as  the  pus 
accumulates  and  the  walls  of  the  bones  may  be  broken  through 
permitting  the  discharge  of  pus  outward,  with  secondary  involve- 
ment of  the  soft  parts  (Plates  XVII,  XIX,  XX).  As  a  result  of 
these  changes,  necrosis  of  greater  or  lesser  portions  of  the  bone 
may  ensue  with  the  formation  of  larger  or  smaller  sequestra 
(PlatesXVI,  XVII,  XVIII). 

In  more  malignant  cases  the  entire  bone  marrow  becomes  in- 
volved. The  cancellous  tissue  of  one  or  both  of  the  epiphyses 
usually  becomes  involved  and  secondary  involvment  of  the  joint 
may  result  (Plate  XIX).  In  young  persons  the  epiphyses  very 
frequently  become  separated  from  the  diseased  shaft  by  the  de- 
struction of  the  cartilage  which  binds  them  together  (Plate  XX). 


—  54  — 


PLATE  XV. 

OSTEOM\'EI-ITIS    OF    THE    LOWER   END   OF    THE    HUMERUS. 

At  the  lower  end  ot  the  Inimerus,  a  short  distance  above  the  epiphyseal 
line,  can  be  seen  a  light  shadow,  due  to  softening  of  the  bone  marrow 
and  to  a  suppurative  osteitis. 

The  medullary  cavity  is  enlarged,  because  of  the  destruction  and  loss 
of  substance  of  the  cancellous  tissue  of  the  bone,  caused  by  the  ostconiyc- 
litic  process. 

The  light  affected  area  is  circumscribed  by  a  dark  zone  of  bone  sclerosis. 

The  periosteum  is  swollen  and  oedematous. 


PLATE  XV. 


■  56- 


PLATE  XVI. 

0STF.OM\-EUTIS    OF    THF,    RADIUS — PRESENCE    OF    SEQUESTRUM. 

The  periosteum  is  swollen  and  ccdematous  around  the  afifected  area 
of  the  radius. 

The  hone  is  swollen,  and  a  dark  and  dense  area  of  hone  sclerosis  cir- 
cumscribes the  lighter  area  of  bone  and  marrow  suppuration. 

Within  this  light  area  is  seen  a  small  sequestrum,  the  result  of  bone 
necrosis. 


PLATE  XVI. 


-S8- 


PLATE  XVII. 

OSTEOMYELITIS  OF  THE  RADIUS — TOTAL  DESTRUCTION  OF  THE  BONE— SECONDARY 
INVOLN-EMENT    OF    THE    SOFT    PARTS. 

The  entire  radius  is  enlarged  and  necrosed. 

The  light  areas  over  the  necrosed  bone  indicate  the  holes  bored  by  the 
pus  through  the  walls  of  the  bone. 

The  secondary  involvement  of  the  soft  parts  is  indicated  by  their 
darker  shadow. 


—  (JO- 


PLAT  K  XVI  IT. 

CHRONIC  OSTEOMEI-ITIS  l)K   THE   I'LNA — EXTENSIVE  DESTRUCTION   OF  THE   SHAFT 
WITH    THE    I'RESENL'E    OF    A    LAUUE    SECJUESTRUM. 

There  is  little  or  no  swelling  of  the  soft  parts. 

The  lighter  shadow  in  the  soft  parts  on  the  ulna  side  of  the  forearm. 
and  with  its  center  lying  opposite  the  space  between  the  two  fragments 
of  the  ulna,  indicates  the  loss  of  substance  in  the  soft  parts  and  the  posi- 
tion of  the  discharging  sinus. 

The  large  sequestrum  shows  the  extent  of  bone  destruction. 

Nature's  effort  at  repair  is  seen  in  the  presence  of  a  new  bone  formation, 
starting  from  the  ends  of  both  fragments  of  the  ulna. 


PLATE  XVIII. 


—  62  — 


PLATE  XIX. 

OSTEOMYELITIS    OF    THE    METACARPAL   BONE    OF   THE   THUML — INVOL\-EMEKT   OF 
THE    SOFT    PARTS. 

The  entire  bone   is   involved. 

The  places  through  which  the  pus  has  bored  through  the  walls  of  the 
bone  can  be  plainly  seen. 

The  cancellous  tissue  of  both  epiphyses  is  involved. 

The  first  carpo-metacarpal  joint  is  also  involved. 

The  extent  of  the  secondary  involvement  of  the  soft  parts  is  vvell 
marked. 


PLATE  XIX. 


•64- 


PLATE  XX. 

OSTEOMYELITIS  OF  THE  ENTIRE   SHAFT  OF  THE    HUMERUS — SEPARATION    OF   THE 

UPPER    EPIPHYSIS — PRESENCE    OF    LARGE    SEQUESTRA — SECONDARY 

INVOLVEMENT   OF   THE    SOFT  PARTS. 

Involvement  and  destruction  of  the  entire  shaft  o:  the  bone. 

The  darker  arers  indicate  the  presence  of  large  sequestra,  the  result 
of  the  bone  necrosis. 

The  holes  bored  by  *.he  pus  through  the  walls  of  the  bone  arc  repre- 
sented by  the  lighter  circumscribed  areas  in  the  bone. 

The  upper  epiphysis  has  become  separated  from  the  diseased  shaft  and 
remains  unaffected  by  the  disease. 

The  darker  shadow  of  the  soft  parts  shows  their  secondary  involvement. 


PLATE  XX. 


-6t- 


TUBERCULOSIS. 

Recognized  on  the  radiogram  by  the  paler  hue  of  the  bone 
shadow,  the  atrophy  of  bone,  the  epiphyseal  prominence  and,  in 
the  later  stages  of  the  disease,  bone  destruction. 

Primary  tubercular  infection  of  the  shaft  of  bones  rarely  oc- 
curs, except  in  the  phalanges,  metacarpal  and  metatarsal  bones. 
It  occurs  most  frequently  in  early  life  and  is  often  associated  with 
involvement  of  the  joints.  The  tuberculous  process  causes  a  dis- 
appearance of  the  lime  salts  associated  with  a  rarifying  and 
formative  process  in  the  bone.  This  new  tissue  formation  is 
simple  granulation  tissue.  Whether  in  or  near  a  joint,  the  dis- 
ease often  simulates  epiphyseal  growth,  which  shows  on  the  radio- 
graph as  enlarged,  pale  and  squared  (Plate  XXI),  when  com- 
pared with  the  normal  side.  As  the  process  advances  bone  de- 
struction takes  place,  with  sometimes  the  formation  of  sequestra 
(Plate  XXII).  The  pus  cavity  may  become  circumscribed  by  a 
process  of  bone  condensation  (Plate  XXIII),  or  may  invade  the 
joints  and  soft  parts  (Plate  XXIV). 


—  68- 


PLATE  XXI. 

TUBERCULOSIS    OF    THE    LOWER    END    OF    THE    FEMUR — SECONDARY    1  NVOLW.MENT 
OF    THE    KNEE    JOINT. 

The  lower  end  of  the  femur  is  enlarged  and  its  lighter  shadow  indicates 
bone  rarefaction. 

The  epiphyseal  line  is  Inst. 

The  epiphyses  of  both  the  fcnuir  and  the  tibia  arc  pale,  enlarged  and 
squared. 

New  formation  granulation  is  present  between  the  patella  and  the  femur, 
between  the  femur  and  tibia,  and  in  the  peri-articular  tissues. 


PLATE  XXI. 


—  70  — 


PLATE  XXII. 

TUBERCULOSIS    OF    THE   BONES    OF    THE    WRIST — PRESENCE    OF    SEQUESTRA. 

Tubercular  involvement  o{  the  lower  end  of  the  radius,  with  destruction 
of  its  articular  surface,  and  loss  of  bone  substance  on  the  outer  surface 
of  the  bone. 

Extensive  involvement  and  destruction  of  the  carpal  bones. 

The  trapezium  is  the  only  one  of  these  that  can  be  distinctly  made  out. 

The  whole  wrist  presents  the  appearance  of  one  mass  of  tubercular 
granulation  tissue,  with  irregular  darker  areas  of  bone  necrosis. 

On  the  ulna  side  the  secondary  involvement  of  the  soft  parts  and  the 
presence  of  pus  are  well  marked. 


PLATE  XXII. 


PLATE  XXIII. 

TUBERCULAR  OSTEOMELITIS  OF  THE  TIBIA — THIS   CASE   HAD   SUFFERED   WITH    AN 

UNDIAGNOSED   PAIN    IN   THE    KNEE  FOR  OVER  ONE   YEAR,   DURING 

WHICH     TIME     HE     WAS     SUBJECTED     TO     NUMEROUS 

AND    VARIED    TREATMENTS. 

Below  the  epiphyseal  line  and  in  a  position  corresponding  to  the  tubercle 
of  the  tibia  is  a  light  shadow  of  bone  rarefaction,  surrounded  by  a  well- 
marked,  dense  shadow  of  bone  sclerosis. 


PLATE  XXIIl. 


—  74  — 


PLATE  XXIV. 

TUBF.RCri.AR    OSTEITIS    OF    THE    TIBIA. 

Below  the  epiphyseal  line,  on  the  anterior  and  inner  surfaces  of  the  tibia, 
is  the  light  shadow  of  bone  rarefaction. 

The  extent  of  the  bone  involvement  and  the  loss  of  bony  substance  can 
be  plainly  seen. 

The  darker  shadow  of  the  soft  parts  to  the  inner  side  of  the  tibia  shows 
the  secondary  involvement  of  these  parts  and  the  presence  of  granulation 
tissue. 


PLATE  XXIV. 


—  77  — 

SARCOMA. 

Osteo-Sarcoma  is  recognized  on  the  radiogram  by  a  shadow 
usually  paler  than  that  of  normal  bone  and  resembling  in  appear- 
ance that  of  zvkite  paint  frosted  on  a  pane  of  glass  by  means  of 
a  piece  of  absorbent  cotton.  This  appearance  is  regarded  as  char- 
acteristic by  the  author.  It  is  due  to  the  fact  that  on  account  of 
the  degenerative  changes  as  well  as  from  the  hemorrhagic  extra- 
vasation, larger  or  smaller  cystic  cavities  develop  and  the  extra- 
vasated  blood  causes  areas  of  pigmentation.  Besides  this,  in 
some  types  of  the  disease,  new  bone  formation  takes  place  in  the 
mass  in  the  shape  of  small  calcified  plates  surrounded  by  a  softer 
zone. 

The  disease  starts  in  the  bone  or  in  the  periosteum  and  may 
even  start  from  the  outside  layers  of  the  periosteum,  involving 
the  soft  parts,  itself  remaining  intact  between  the  bone  and  the 
growth  (Plate  XXA'').  Most  frequently  a  new  bone  is  formed 
beneath  the  periosteum,  so  that  the  tumor  is  encased  in  a  thin 
bony  shell  (Plates  XXVI,  XXVIII,  X^'X).  Perforating  this 
and  the  periosteum  the  tumor  invades  the  soft  parts,  its  outline 
becomes  lost  and  its  shadow  fades  away,  blending  with  that  of 
the  soft  parts. 

In  upwards  of  two-thirds  of  the  cases  of  sarcoma  of  the  long 
bones,  the  growth  will  be  found  in  one  end  of  the  bone,  the  lower 
end  in  the  femur  and  the  upper  end  in  the  tibia  and  humerus, 
probably  starting  in  the  epiphyses,  but  very  rarely  invading  the 
joint,  except  in  the  later  stages  of  the  disease  (Plate  XXVII).  In 
a  few  cases,  especially  those  of  the  femur  and  tibia,  it  begins  in 
the  middle  of  the  shaft  and  here  it  is  always  of  the  periosteal 
type,  forming  a  fusiform  enlargement  of  the  shaft  in  the  early 
stages.  Pathological  fractures  due  to  this  disease  are  not  infre- 
quent (Plates  XXVIII,  XXIX). 

In  one  case  of  sarcoma  (Plate  XXX),  in  which  the  character- 
istic frostcd-likc  appearance  was  not  present  operation  revealed  a 
cavity  walled  by  a  thin  shell  of  bone  and  filled  with  a  homogeneous 
substance  resembling  unorganized  granulation  tissue  which  could 
be  easily  scooped  out.  The  pathologist's  report  was  giant  cell  sar- 
coma. 

This  type  of  sarcoma,  the  myelogenous  or  medullary  giant  cell, 
is  prone  to  develop  cysts  in  bone,  and  these  cysts  are  often 
filled  with  blood  and  comprise  the  so-called  bone  aneurisms.  The 
absence  of  cystic  cavities  and  pigmentation,  the  result  of  degene- 
rative changes  and  hemorrhagic  extravasation  and  of  calcified 
plates  so  gjsnerally  found  in  the  other  types  of  osteo-sarcoma, 
account  for  the  absence  of  the  characteristic  appearance  men- 
tioned above. 


-78- 


PLATE    XXV. 

SARCOMA   OF   THE   SOFT   PARTS   OF  THE  THIGH — NO   INVOLVMENT  OF  THE  FEMUR 

— X-RAY    FINDING   CONFIRMED   BY    A    CAREFUL   EXAMINATION 

OF   THE   LIMB   AFTER   A    HIP   AMPUTATION. 

The  dark  mottled  shadow  surrounding  the  femur  and  seen  more  espe- 
cially behind  that  bone  is  a  sarcomatous  tumor  of  the  soft  parts  of  the 
thigh. 

The  bone  is  not  involved. 

Its  normal  outline  can  be  distinctly  made  out  through  the  abnormal 
shadow. 


PLATE  XXV. 


•8o  — 


PLATE    XXVI. 

OSTEO-SARCOMA    OF   THE    UPPER    END    OF    THE    HUMERUS — SECONDARY    INVOLVE- 
MENT OF    THE    SOFT    PARTS. 

The  upper  extremity  of  the  humerus  is  enormously  enlarged,  and  its 
normal  structure  is  replaced  by  the  characteristic  appearance  of  osteo- 
sarcoma. 

The  disease  has  perforated  the  thin,  bony  envelope  encasing  the  tumor 
notably  on  the  inner  and  outer  borders,  and  in  these  places  it  invades  the 
soft  parts ;  its  outline  is  lost,  and  its  shadow  blends  with  that  of  the  latter 
tissues. 

The  shoulder  joint  is  not  involved. 


PLATE  XXVI. 


—  82  — 


PLATE  XXVII. 

IMMENSE   OSTEO-SARCOMA    OF    THE   LOWER   END    OF    THE    FEMUR — INVOLVEMENT 
OF     THE     KNEE     JOINT. 

This  skiagram  sliows  the  latter  stages  of  osteo-sarcoma. 

A  large  mass,  presenting  the  characteristic  appearance  of  osteo-sarcoma, 
replaces  the  normal  shadovi's  of  the  lower  end  of  the  femur  and  of  the 
knee  joint. 

The  peri-articular  tissues  and  surrounding  soft  parts  are  involved. 


PLATE  XXVII. 


-84- 


PLATE  XXVIII. 

OSTEO-SARCOMA  OF  THE   UPPER  END  OF   THE   HUMERUS — PATHOLOGICAL 
FRACTURE. 

The  upper  end  of  the  humerus  is  enlarged,  and  its  normal  shadow  is 
replaced  by  the  characteristic  appearance  of  osteo-sarcoma. 

The  disease  has  perforated  the  thin,  bony  envelope  encasing  the  growth 
on  the  inner  border,  and  in  that  location  it  invades  the  soft  parts. 

There  is  a  pathological  fracture  present. 

The  contrast  between  the  diseased  bone  above  the  fracture  and  the 
unaffected  shaft  below  it  is  well  marked. 

The  soft  parts  about  the  fractured  ends  of  the  diseased  bone  are  in- 
volved by  the  disease. 


PLATE  XXVIII. 


—  86  — 


PLATE  XXIX. 

OSTEO-SAECOMA   OF   THE   FEMUR — PATHOLOGICAL   FRACTURE. 

The  tumor  mass,  including  the  ends  of  the  fractured  bone  and  involving 
the  surrounding  soft  parts,  presents  the  characteristic  appearance  of  osteo- 
sarcoma. 


PLATE  XXIX. 


PLATE  XXX. 

OSTEO-SAECOMA   OF  THE  LOWER  EXn  OE  THE  RAPTl'S — CIAXT   TELL   VARIETY. 

The  characteristic  appearance  of  sarcoma  is  aljsent. 

A  tumor,  encased  in  a  thin  bony  shell  and  filled  with  tissue  resembling 
the  tubercular  granulation  tissue,  replaces  the  normal  bony  shadow  of 
the  lower  end  of  the  radius. 

The  outline  of  the  tumor  is  distinct,  ar.d  it  can  be  well  made  out,  sepa- 
rated from  the  normal  soft  parts  above  it  by  a  thin  bony  wall. 

The  normal  inner  border  of  the  radius  is  lost  in  the  new  growth. 

Its  articular  surface  remains  intact. 


PLATE  XXX. 


•91  — 


SYPHILIS. 

Distinguised  on  the  radiogram  by  the  darker  hue  of  bone 
and  the  thickened  and  irregular  outline  of  the  periostal  cover- 
ing, due  to  the  condensing  osteitis  in  and  on  the  surface  of  the 
bone  and  the  deposit  of  new  bone  under  the  periosteum.  The 
disease  usually  commences  in  the  periosteum,  which  becomes 
thickened  and  infiltrated  (Plate  XXXII),  with  or  without  the 
formation  of  the  bony  matter.  As  the  disease  progresses,  the 
channels  in  the  bone,  enlarged  by  a  rarefying  osteitis,  forming 
irregular  defects,  are  filled  with  new  fibrous  tissue  (Plates 
XXXIII,  XXXIV).  The  process  is  not  infrequently  associated 
with  suppuration  (Plate  XXXV,  and  the  necrosis  of  a  larger 
or  smaller  portion  of  bone  (Plate  XXXVI). 


—  92  — 


PLATE  XXXI. 

SYPHILITIC   GUIIMATA   OF   THE    JIUSCLES   OF    THE    THIGH. 

The  shadow  seen  in  the  muscles  of  the  anterior  surface  of  the  thigh  is 
a  mass  of  sclerotic  tissue  of  s\-philitic  origin. 


PLATE  XXXI. 


—  94- 


PLATE  XXXir. 


SYPHILITIC    TERIOSTITIS    OF    THE    TIBIA. 


Tlic  periosteum  is  swollen   and   raised. 

The  shadow  is  darker  than  in  the  other  forms  of  periostitis,  and  its 
outhne  is  rough  instead  of  smooth   (see  Plate  XXXVII). 

The  irregular  darker  areas  indicate  the  presence  under  tlie  periosteum 
uf  new  formation  sclerotic  or  bone  tissue,  due  to  the  syphilitic  process. 


PLATE  XXXII. 


-96- 


PLATE  XXXIII. 

SYPHILIS   OF   THE   I,0\VER   END   OF  THE   RADIUS. 


The  bone  shadow  is  mucli  darker  than  the  normal. 
Its  outline  is  rough  and  presents  irregularities. 


PLATE  XXXIII. 


PLATE  XXXIV. 

SYPHILIS     OF     THE     FEMUR — CALCAREOU  S    HEGENERATION     OF     THE     POPLITEAL 
ARTERY — PRESENCE  OF   A   PHLEBOLITH    IN   THE   POPLITEAL  VEINS. 

The  normal  shadow  of  the  femur  is  replaced  by  the  darker  shadow  of 
osteo-sclerosis.     Its  outline  is  rough  and  presents  irregularities. 

The  popliteal  artery  has  undergone  calcareous  degeneration,  and  is 
visible  in  its  whole  course  throughout  the  skiagram. 

The  small  oval  shadow  behind  the  femoral  condyle  is  a  phlebolith  in 
one  of  the  popliteal  veins. 


PLATE  XXXIV. 


—  lOO  — 


PLATE  XXXV. 

SYPHILIS     OF    THE    FEMUR — NECROSIS     OF    BON'E — INVOL\"EMENT    OF    THE     SOFT 
PARTS. 

Tlie  darker  shadow  of  the  bone,  its  rough  outline  presenting  irregu- 
larities, forms  a  typical  picture. 

Evidence  is  also  present  of  destruction  of  bone,  with  loss  of  substance 
and  of  suppuration,  with  secondary  involvement  of  the  soft  parts. 


PLAI  !■:  XXX\\ 


PLATE  XXXVr. 

SYPHILIS    OF    THE    UI.NA — EXTENSIVE    LOSS    OF    SUBSTANCE. 

Compare  tbc  darker  shadow  of  the  ulna  with  tlie  normal  shadow  of  the 
radius. 

The  skiagram  also  shows  the  extent  of  the  loss  in  bony  substance  and 
the  presence  of  necrosed  bone. 


PLATE  XXXVI. 


I05  — 


PERIOSTITIS. 

(Plate  XXXVII)  :  Periostitis  can  only  be  distinuished  on 
the  radiogram  when  there  is  considerable  thickeining  of  the  peri- 
osteum or  some  exudate  existing  between  it  and  the  bone.  It  is 
then  recognized  as  a  circumscribed  shadow,  darker  than  the  nor- 
mal soft  parts.  This  shadow  may  be  large  or  small,  entirely 
surround  the  bone  or  appear  only  as  a  raised  dark  shadow  upon 
one  of  the  bone  surfaces.  If  there  is  secondary  involvement  or 
caries  of  the  bone  this  will  also  show  plainly  in  the  radiogram. 
The  results  of  periostitis,  the  formation  of  fibrous  or  osseous 
tissue  between  the  periosteum  and  the  bone,  can  also  be  plainly 
seen  as  dark  circumscribed  areas  next  the  bone. 


—  io6  — 


PLATE  XXXVII. 

PERIOSTITIS    OF    THE    TIBIA. 

The  periosteum  is  swollen  and  raised,  and  there  is  an  exudate  between 
it  and  the  anterior  surface  of  the  tibia. 

The  darker  circumscribed  area  on  the  anterior  border  of  the  bone  is  a 
new  bone  formation,  caused  by  the  periostitis. 


PLATE  XXXVII. 


—  I09  — 


RICKETS. 

Rickets  is  recognized  by  the  pale  bone  shadow,  the  enlarged 
medullary  canal  and  the  bending  of  the  epiphyses  or  the  shaft 
or  both  of  the  long  bone. 

The  condition  usually  occurs  during  the  first  two  years  of  life, 
but  it  may  be  congenital  or  may  occur  as  late  as  the  twelfth  year. 
Proper  calcification  does  not  take  place.  At  the  same  time,  the 
dilatation  of  the  medullary  cavity  goes  on  irregularly  and  often  to 
an  excessive  degree.  The  cartilaginous  and  sub-periosteal  cells 
grow  with  increased  rapidity  and  exhuberance  and  in  an  irregular 
manner.  As  a  result  the  bones  do  not  possess  solidity  and  cannot 
resist  the  traction  of  the  muscles  (Plate  XXXVIII)  or  outside 
pressure.  The  epiphyses  may  be  displaced  or  bent,  especially  in 
the  ribs,  less  frequently  in  the  long  bone.  The  long  bones  or  the 
pelvic  bones  may  be  bent  in  a  variety  of  forms  (Plates  XXXIX, 
XL). 


PLATE  XXXVIII. 


KACHITIC   BONES. 


The  shadow  of  the  bones  is  paler  than  normal. 

The  upper  and  inner  end  of  both  tibias;  just  below  the  epiphyseal  line, 
is  bent  downwards. 
There  is  a  slight  bending  of  the  shafts  of  both  tibias. 


PLATE  XXXVIII. 


PLATE  XXXIX. 

RACHITIC    BOXES. 

The  lowi-T  and  inner  end  of  both  femurs,  just  above  the  epiphyseal  line, 
is  bent  upwards,  and  the  upper  and  inner  end  of  botli  tibias,  just  above 
the  epiphyseal  line,  is  bent  downwards. 

The  shafts  of  both  femurs  and  tibias  are  slightly  bent. 


PLATE  XXXIX. 


—  114  — 


PLATE  XL. 

RACHITIC  BOXES. 

This  skiagram  shows  the  pale  shadow  and  the  enlarged  medullary  cavi- 
ties of  both  tibias. 

There  is  a  marked  bending  of  the  shafts  of  both  tibias. 


PLATE  XL. 


—  117  — 


SCURVY. 

Scurvy,  alfnough  not  truly  a  disease  of  bones,  causes  frequently 
sub-periosteal  hemorrhages,  which  are  most  generally  found  at 
the  lower  extremity  of  the  long  bones  (Plates  XLI,  XLTI). 


PLATE  XLI. 

SUB-PERIOSTEAl,    HEMORRHAGE    IN'    SCURVY — ACUTE    STAGE. 

The  sub-periosteal  hemorrhage  is  represented  on  the  skiagram  as  a  light 
fusiform  shadow,  lying  between  the  anterior  surface  of  the  femur  and 
the  soft  parts  on  the  anterior  surface  of  the  thigh. 


PLATE  XLI. 


PLATE  XLTI. 

EXTENSm;    SUB-PERIOSTEAL    HEMORRHAGE    IM    SCURVY — CHRONIC    STAGE. 

The  hemorrhage  shows  as  a  dark  gray  shadow,  between  the  bone  and 
the  raised  periostenm.  It  extends  from  the  level  of  the  lesser  trochanter 
to  the  epiphyseal  line  of  the  right  femur. 

The  shadow  of  the  bone  is  darker  than  that  of  the  other  unaffected 
side,  because  the  hemorrhage  surrounded  the  bone. 

The  shadow  of  the  hemorrhagic  area  is  darker  than  in  the  preceding 
plate,  because  the  clot  was  larger  and  organized. 


PLATE  XLII. 


123  — 


OSTEOAIATA. 

(Plate  XLIII:  New  bone  growths  may  start  from  the  peri- 
osteum— exostosis — or  they  may  start  from  the  interior  of  the 
bone — enostosis.  The  former  may  appear  anywhere ;  the  latter 
are  seldom  found  outside  of  the  bones  of  the  head.  They  would 
be  recognized  on  the  skiagram  as  irregular,  dark  masses,  attached 
to  the  bone. 


OSTEOID  CHONDROMA. 

(Plate  XLIV)  :  Osteoid  chondroma  develop  beneath  the  peri- 
osteum most  frequently  in  the  femur  or  tibia,  near  the  knee  joint, 
forming  a  club-shaped  enlargement  of  the  bone,  resembling  some- 
what the  immature  bone  tissue  seen  beneath  the  periosteum  in 
developing  bone. 


—  124  — 


PLATE  XLIII. 

MULTIPLE  EXOSTOSES   OF   THE  BONES   OF   THE   FOREARM. 

The  irregular  dark  shadows  projecting  from  the  sides  of  the  ulna  and 
radius,  near  their  lower  ends,  represent  the  new  bone  growth  from  the 

periosteum. 


PLATE  XLIII. 


126  — 


PLATE  XLIV. 

OSTEOID    CHONDROMA   OF    THE   FEMUR. 

The  enlargement  of  the  inner  condyle  of  the  femur  is  well  marked. 


PLATE  XLIV. 


—  128  — 


PLATE  XLV. 


CYST     OF     BONE. 


Cyst  of  bones  is  rarely  foiiiul  outside  of  the  bones  of  the  head.  It  is 
usually  the  result  of  a  former  osteitis.  It  could  not  be  diagnosed  on  a 
radiogram  from  a  small  medullary  giant  cell  sarcoma  before  the  latter 
breaks  through  the  bony  wall. 

In  the  Plate  a  cystic  cavity  can  be  seen  in  the  radius  about  its  middle 
third. 

The  walls  of  the  cavity  are  thin  and  throw  a  very  faint  shadow.  They 
were  formed  of  periosteum  and  thin  new  bone  formation. 

The  cavity  was  tilled  with  a  bloody  and  serous  liquid. 


PLATE  XLV. 


—  130  — 

DIFFERENTIAL  DIAGNOSIS. 

Of  the  disease  discussed  in  this  part  the  one  which  is  most 
likely  to  be  confounded  with  some  other  disease  is  osteo-sarcoma ; 
because  of  that  and  because  of  the  serious  import  of  such  a  mis- 
take, we  shall  devote  a  few  lines  to  its  differential  diagnosis. 

Asteo-sarcoma  must  be  differentiated  from  osteo-myelitis,  tu- 
berculosis of  bone,  syphilis  of  bone,  osteomata,  cyst  of  bone, 
scurvy  and  exhubrant  callous  formations. 

All  cases  of  osteo-sarcoma  seen  by  the  author,  with  the  ex- 
ception of  one  case  of  medullary  giant  cell  sarcoma,  presented 
the  characteristic  frost-like  appearance. 

Large  Osteomata :  Either  exotosis  or  enostosis  are  the  only 
other  diseases  of  the  bone  presenting  shadows  which  have  any 
resemblance  to  the  characteristic  appearance  of  sarcoma.  This 
shadow,  however,  is  much  denser,  does  not  involve  the  entire  bone 
segment  and  does  not  merge  into  the  soft  parts. 

Osteomyelitis  shows  in  circumscribed  cases  the  light  central 
shadow  surrounded  by  the  dark  rim  of  osteosclerosis  ;  in  extensive 
cases,  with  extension  of  inflammation  to  the  soft  parts,  there  is  a 
honeycombed  appearance  of  the  bone,  with  or  without  the  pres- 
ence of  sequestra.  While  in  sarcoma  the  normal  bone  shadow 
disappears  and  is  replaced  by  the  characteristic  shadow,  which 
fades  away  into  the  surrounding  soft  parts. 

Tuberculosis  of  Bone  shows  the  indefinite  pale  shadow  and  the 
bone  atrophy.  It  nearly  always  begins  at  the  epiphyses  and  very 
frequently  spreads  to  the  joint.  Sarcoma,  quite  the  contrary, 
very  rarelv  involves  the  joint,  except  in  the  later  stages  (see 
Plate  NNN). 

Syphilis  of  Bones  shows  darker  shadows.  The  periosteum 
often  presents  an  irregular  raised  appearance  over  a  greater  area 
than  is  seen  in  sarcoma,  and  there  is  no  blending  or  extension  to 
the  soft  parts  as  in  the  latter  disease. 

Cyst  of  Bone  cannot  be  dift'erentiated  from  a  small  medullary 
giant-celled  sarcoma.  It  lacks  the  characteristic  appearance  pres- 
ent in  other  types  of  sarcoma. 

Scurvy :  When  the  sub-periosteal  hemorrhage  is  extensive  and 
the  clot  organized,  could  be  mistaken  for  the  form  of  sarcoma, 
beginning  in  the  outer  layers  of  the  periosteum  and  invading  the 
soft  parts,  leaving  the  bone  intact.  The  bone  outline  is  clearer 
and  more  distinct,  and  the  outline  of  the  tumor  is  sharp  in  scurvy 


—  131  — 

and  does  not  blend  with  and  become  lost  in  that  of  the  soft  parts. 
The  periosteum  is  raised,  but  smooth,  not  close  to  the  bone,  and 
its  outer  layer  rough  and  forming  part  of  the  tumor  mass,  as  is 
the  case  in  sarcoma  (see  Plates  XXV  and  XLII) 

Exuberant  Callous  Formation  could  be  mistaken  for  a  sarcoma 
of  bone  with  pathological  fracture.  The  characteristic  appear- 
ance of  osteo-sarcoma  would  be  absent  (see  Plate  XXIX). 


ARTHRITIS. 

The  synovial  sac  becomes  filled  with  serum,  sero-fibronous 
fluid  or  pus,  depending  upon  the  nature  of  the  infective  agency. 
The  skiagram  shows  the  increased  interosseous  space  and  the 
distended  joint  capsule.  The  density  of  the  shadow  will,  of 
course,  depend  upon  the  nature  of  the  fluid  in  the  synovial  sac. 

Mild  cases  undergo  resolution.  The  more  malignant  ones  cause 
extensive  destruction  of  cartilage  and  bone.  The  majority  of 
cases  become  chronic.  Here  we  find  the  following  joint  changes : 
At  first  the  synovial  membrane  is  congested  and  its  tufts  are 
prominent  (Plate  XLVI).  Later  there  is  more  or  less  destruc- 
tion of  the  synovia,  with  the  formation  of  small  adhesions  (Plate 
XLVII)  and  the  tufts  become  large  and  projecting.  As  the 
disease  advances  the  cartilaginous  surface  is  destroyed  and  re- 
placed by  granulation  tissue.  Fibrous  (Plate  XLVIII)  and  bony 
(Plate  XLIX)  ankylosis  often  result. 


—  132- 


PLATE  XLVI. 

ARTHRITIS    OF   THE    KXEE   JOINT. 

The  congestion  of  the  synovial  membrane  and  the  prominence  of  its 
tufts  are  well  represented  on  the  skiagram  by  the  gray  shadow  with 
fringe-like  lower  free  border,  in  what  is  normally  a  clear  space  between 
the  lower  extremities  of  the  patella  and  femur  and  the  upper  extremity 
of  the  tibia. 

The  tendon  patella  is  also  visible. 


PLATE  XLVI. 


—  134- 


PLATE  XLVII. 

ARTHRITIS  OF  KNEE  JOINT — SMALL  ADHESION. 

A  small  band  of  adhesion  between  the  spine  of  the  tibia  and  the  ex- 
ternal femoral  condyle  can  be  plainly  seen. 

The  shadow  of  the  inter-articular  space  is  darker  than  normal. 


PLATE  XLVII. 


136 


PLATE  XLVIII. 

FIBROUS    ANKYLOSIS    OF    THE   ELBOW    JOINT. 

The  fibrous  bands  of  adhesions  between   the   articular  surfaces  of  the 
humerus  and  ulna  can  be  distinctly  made  out. 


PLATE  XLVIII. 


-138- 


PLATE  XLIX. 

BOXY    ANKYLOSIS    OF    THE    AXKLE   JOINT. 

The  joint  is  destroyed,  and  one  mass  of  bony  tissue  is  present. 


PLATE  XLIX. 


—  141  — 


RHEUMATOID  ARTHRITIS. 

This  name  has  been  applied  to  a  variety  of  chronic  inflamma- 
tion of  joints  which  combine  witli  degeneration  of  parts  of  the 
joint  and  the  new  formation  of  bone  may  result  in  marked  de- 
formities of  the  part.  The  capsules  are  thickened  and  sclerosed, 
the  tufts  of  the  synovial  membrane  are  changed  into  cartilage, 
new  bone  grows  from  the  articular  cartilages,  from  the  joint 
capsules,  and  even  from  the  ligaments  (Plate  L). 

As  a  result  of  the  changes  which  take  place  in  the  basement 
membrane  and  in  the  cartilages,  the  latter  become  destroyed  from 
pressure  during  the  movements  of  the  joint  and  the  bone  is  laid 
bare.  This  is  shown  in  the  skiagraph  by  disappearance  of  the 
normal  articular  shadow  (Plate  LI). 

The  ends  of  the  bones  are  much  deformed.  They  are  flattened 
and  made  broader  by  irregular  new  growth  of  bone,  while  at  the 
same  time  they  atrophy.  The  new  growth  of  bone  starts  from  the 
articular  cartilage. 


142  — 


PLATE  L. 

RHEUMATOID    ARTHRITIS    OP    THE    WRIST — IIYPERTROrHIC    TYPE. 

There  is  a  marked  deformity  of  the  wrist. 

The  articular  cartilage  of  the  radius  is  destrojed. 

The  normal  inter-articular  shadows  are  absent.  The  carpal  bones  can- 
not be  made  out  from  each  other,  and  they  can  barely  be  separated  from 
the  radius  and  ulna  above  and  the  metacarpal  bones  below. 

New  growth  formations,  starting  from  the  margins  of  the  articular 
cartilages  of  the  radius  and  ulna  and  from  the  ligaments,  can  be  seen. 


PLATE  L. 


—  144 


PLATE  LI. 

RHEUMATOID    ARTHKITIS    OF    THE    KNEE — ATROPHIC    TYPE, 

The  inter-articular  sliadow  in  tlic  external  half  of  the  joint  is  darker 
than  normal. 

In  the  inner  half  the  absence  of  the  inter-articular  clear  shadow  indi- 
cates the  almost  complete  destruction  and  disappearance  of  the  articular 
cartilage. 


PLATE  LI. 


—  147 


TUBERCULAR  ARTHRITIS. 

This  affection  usually  begins  in  the  synovial  membrane  of  the 
joint  (Plate  LII),  or  it  may  extend  to  the  joint  from  adjacent 
bone.  It  is  characterized  by  the  formation  of  tubercle  tissue  and 
granulation  tissue  and  is  usually  associated  with  secondary  in- 
flammation and  degenerative  changes  of  the  surrounding  part. 
This  disease  is  most  common  in  children  and  young  persons,  and 
usually  affects  one  of  the  larger  joints  (Plate  LIII).  It  is  rec- 
ognized on  the  radiogram  by  the  paler  hue  of  granulation  tissue. 
As  the  disease  advances  and  the  articular  ends  of  the  bones  be- 
come involved  this  is  plainly  seen  on  the  X-ray  negative  by  the 
paler  shadow  and  the  atrophy  of  the  affected  bone  (Plate  LR'). 
Later  the  area  and  extent  of  the  bone  destruction  (Plate  LV), 
with  resulting  deformities,  show  distinctly  (Plate  LVI). 


—  148  — 


PLATE  LII. 

TUnERCULAR  ARTHRITIS  OF  THE   KNEE- -EARLY  STAGE. 

The  dark  oval  shadow,  inchiding  the  knee  joint  and  the  peri-articular 
tissues,  indicates  the  presence  of  tuhercular  granulation  formations  in  the 
synovial  membrane  of  the  joint,  associated  with  secondary  inflammation 
of  the  surrounding  soft  parts. 

The  lower  epiphyses  of  the  femur  is  pale. 

The  inter-articular  space  is  much  greater  than  normal. 


PLATE  LII. 


—  ISO- 


PLATE  LIII. 


TUBERCULAR   ARTHRITIS    OF   THE    HIP. 


The  normal,  clear,  inter-articular  space  is  replaced  by  the  light  gray 
shadow,  indicative  of  synovial  congestion  and   infiltration. 

The  head  and  neck  of  the  femur  and  the  pelvic  bones  are  paler  than 
normal. 

The  light  gray  hue  of  the  bones,  just  above  and  to  the  inner  side  of  the 
acetabulum,  denotes  bone  rarefaction  and  the  presence  of  new  formation 
tubercular  granulation  tissue. 


i'LA'lE  iJir. 


152  — 


PLATE  LIV. 

TUBERCULAR  C0X4TIS   OF   THE   RIGHT    HIP — FIRST   STAGE — CHILD  d   YEARS   OLD. 

The  difference  in  the  size  of  the  hip  and  the  pelvis  in  the  right  side  is 
not  real,  it  is  due  to  the  tihing  of  the  pelvis,  caused  by  the  rigid  and 
fixed  position  of  the  affected  hip. 

The  bones  are  paler  on  the  right  side. 

The  inter-articular  and  epiphyseal  lines,  so  distinct  on  the  healthy  side, 
are  indistinct  and  blocked  on  the  affected  one. 

A  distinct  oval  light-gray  shadow  embracing  the  acetalulum  and  the 
head  and  neck  of  the  femur,  is  seen  on  the  right  side. 

This  is  indicative  of  congestion  of  the  synovial  membrane  and  of  the 
presence  of  fluid  in  the  joint. 

There  is  no  involvement  of  the  bones.  The  white  line  surrounding  the 
upper  epiphysis  of  the  femur  is  produced  by  a  tracing  on  the  X-ray 
negative  made  to  indicate  the  position  of  this  epiphysis. 

This  little  patient  died  of  pneumonia  about  one  week  after  this  skia- 
gram was  made,  and  the  X-ray  findings  were  confirmed  at  the  autopsy. 


PLATE  LIV. 


154  — 


PLATE  LV. 

TUBERCLXAR  COXITIS  OF  THE  RIGHT  HIP — SECOND  STAGE — BONE  INVOLVEMENT — 
CHILD   4   YEARS  OLD. 

The  femur  and  the  pelvic  bones  are  pale  and  atrophied  on  the  affected 
side. 

The  gray  shadow  on  the  right  side,  including  the  hip  joint  and  the  sur- 
rounding soft  parts,  shows  the  extent  of  the  tubercular  involvement  of 
the  joint  and  the  peri-articular  tissues. 

The  acetabulum,  the  head,  neck  and  great  trochanter  of  the  femur  are 
involved:  the  bone  rarefaction  and  infiltration,  with  the  new  formation 
tubercular  granulation  tissue,  can  be  seen  extending  to  a  line  slightly 
below  the  inter-trochanteric  line. 


PLATE  LV. 


-156- 


PLATE  LVI. 

TfRERCrLAR   COXITIS    OF    THE   RIGHT    HIP — THIRD    STAGE — BOXE   DESTRUCTION — 
CHILD    4    YEARS    OLD. 

The  affected  femur  is  paler  than  the  normal  one. 

The  right  pelvic  bones  and  femur  are  atrophied. 

The  acetabulum  and  the  head  of  the  femur  are  destroyed. 

The  involvement  of  the  femur  extends  to  a  point  below  the  inter- 
trochanter  line. 

The  gray  shadows  in  the  soft  parts  surrounding  the  upper  extremity  of 
the  femur  and  the  hip  joint  show  theextent  of  involvement  of  these  parts. 

The  destruction  of  the  pelvic  bones  and  the  involvement  of  the  pelvic 
tissues  are  clearly  visible. 


PLATE  LVI. 


158- 


PLATE    LVII. 


LOOSE    SEMI-LUNAR    CARTILAGE. 


This  Plate  sliows  a  loose  outer  semi-lunar  cartilage  slightly  dislocated 
inwards. 

The  dislocation  inwards  of  the  external  semi-lunar  cartilage  of  the 
tibia  can  be  distinctly  made  out. 

The  separation  between  the  loose  semi-lunar  cartilage  and  the  upper  end 
of  the  tibia  is  well  marked. 


PLATE  LVII. 


—  i6i 


PART  III. 
FRACTURES,   DISLOCATIONS,   FOREIGN    BODIES. 


FRACTURES. 


In  establishing  the  diagnosis  of  fracture  two  skiagrams  of  the 
affected  part  should  always  be  made  whenever  this  is  possible. 
One  of  these  must  be  an  antero-posterior  view  of  the  limb,  and 
the  other  a  lateral  view.  No  exception  to  this  rule  should  be 
made  when  skiagraphing  the  wrist  and  hand.  The  practice  to 
take  a  palmar  and  then  a  dorsal  view  is  faulty.  The  second  ex- 
posure in  every  instance  should  be  made  with  the  part  lying  in 
a  position  which  is  at  right  angles  to  that  assumed  during  the 
first  exposure. 

In  that  way  alone  accurate  information  can  be  obtained  about 
the  nature  of  the  fracture,  the  position  of  the  fragments  and  the 
formation  of  callous,  and,  in  some  rare  cases,  the  presence  of  a 
fracture. 

One  view  may  show  the  fragments  in  apparently  perfect  op- 
position, while  the  other  shows  considerable  displacement  (Plates 
LVIII  and  LIX).  Or  one  view  may  show  a  fracture,  and  the 
other  view  shows  none  (Plates  LX  and  LXI). 

Whenever  from  the  nature  of  the  part  (hip,  spine,  shoulder, 
ribs,  clavicle,  scapula),  or  from  ankylosis  or  deformity  (fixed 
flexed  knee,  etc.),  only  one  view  can  be  made,  this  should  be  done 
with  the  part  lying  as  close  to  the  plate  as  possible  and  in  as  near 
the  normal  position  as  possible.  In  such  cases  a  correct  diagnosis 
can,  as  a  rule,  only  be  made  after  a  careful  study  of  the  skia- 
grams and  after  comparison  with  normal  skiagrams  (Plates  LXII 
and  LXVI). 


l62 — ■ 


PLATE  LVIII. 

FRACTURE    OF    THE    RIGHT    FEMUR — ANTERO-POSTERIOR    VIEW — SAME     CASE     AS 
PLATE     LIX. 

A  shadow  darker  than  that  of  the  soft  parts,  but  not  as  dark  as  that 
of  the  bone,  can  be  seen  on  each  side  of  the  femur,  about  midway  between 
its  epiphyseal  line  and  the  upper  border  of  the  skiagram.  At  that  same 
point  the  bone  shadow  is  much  darker. 

The  explanation  of  these  shadows  is  seen  in  the  next  Philc.  The  first 
shadow  is  due  to  callous  formation,  and  the  darker  shadow  of  the  bone 
is  due  to  overlapping  of  the  fractured  ends  of  the  femur. 


PLATE  LVIII. 


—  164  — 


PLATE  LIX. 

FRACTURE   OF   THE   RIGHT   FEMUR — LATERAL  VIEW — SAME   CASE    AS    PLATE    LVIU. 

The  fractured  ends  of  the  femur  overlap  and  are  displaced  in  an 
antero-posterior  direction. 

Callous  is  thrown  out  from  the  ends  of  both  fragments  and  holds  the 
bones  together. 


PLATE  LIX. 


— 166  — 


PLATE  LX. 

GUN'-SHOT  FRACTURE  OF  THE  LOWTR  END  OF  THE  HUMERUS — ANTERO-POSTERIOR 
VIEW — SAME  CASE  AS   PLATE  LXI. 

The  fracture  line  runs  into  the  joint. 

The  spHntered  bullet  lies  close  to  the  upper  end  of  the  fracture. 


PLATE   LX. 


—  i68  - 


PLATE  LXI. 

GUN-SHOT   FRACTURE   OF   THE  LOWER   END   OF   THE   HUMERUS — LATERAL  VIEW — 
SAME    CASE    AS     PLATE    LX. 

No  fracture  can  be  detected  in  this  skiagram. 

There  is  no  shadow  due  to  callous  formation  or  to  the  overlapping  of 
the  fractured  ends  of  bone  as  in  the  preceding  case   (Plates  LVIII-LIX). 


PLATE  LXI. 


— ■  170 — • 


PLATE  LXII. 

IMPACTED  FRACTURE   OF   THE   SURGICAL    NECK   OF   THE   FEMUR — CLINICAL 
DIAGNOSIS    WAS    CONTUSION    OF    HIP. 

Compare  with  the  skiagram  of  a  normal  hip  (Plate  X).  Notice  the 
higher  position  of  the  greater  trochanter  and  the  abnormal  angle  formed 
by  the  head  and  neck  of  the  femur  with  the  shaft. 


PLATE  LXII. 


172^ 


PLATE  LXIII. 

FRACTUKE   OF   THE    ANOTOMICAL    NECK    OF    THE    FEMUR — CLINICAL    DIACN'OSIS 
WAS    CONTUSION    OF    HIP. 

The  greater  trochanter  is  in  a  higher  position  than  normal. 

The  head  is  in  the  acelabuhim. 

The  fracture  hne  runs  through  the  neck  of  the  femur. 


PLATE  LXIII. 


—  174  — 


PLATE  LXIV. 


FRj\CTURE    OF    THE    PELVIC    BONES — FRACTURE    LINE   RUNS    THROUGH    THE 
ACETABULUM. 


PLATE  LXIV. 


-176- 


PLATE  hXV. 

FRACTURE  OF  THE   UPPER  END  OF   THE   SHAFT   OF  THE  FEMUR — THE   FRACTURE 
RUNS    THROUGH    THE    INTER- TROCHANTERIC   LINE   OF    THE   FEMUR. 


PLATE  LXV. 


178- 


PLATE  LXVI. 

FRACTURE   OF   THE   ASTR(\CALUS — tXINICAL    DIAGNOSIS,    CONTUSION    OF   THE 
ANKLE. 

The  fracture  becomes  at  once  apparent  when  comparison  is  made  with 
the  skiagram  of  a  normal  ankle  (Plate  XIII).  Without  such  assistance 
this  is  a  very  difficult  plate  to  interpret. 


PLATE  LXVl. 


—  i8o- 


PLATE  LXVII. 

FRACTURE   OF    THE    PATELLA — SKIAGRAM    TAKEN    ABOUT    3    MONTHS    AFTER 
SUTURING  OF  THE  CAPSULE. 

The  functional  result  was  perfect. 

Notice  the  separation  and  apparent  lack  of  union  between  the  two  frag- 
ments. 

This  is  due  to  the  fact  that  the  callous  does  not  become  completely 
ossified  before  between  nine  and  twelve  months. 


PLx\TE  LXVII. 


-i83- 


DISLOCATIONS. 

With  the  exception  of  the  hip  and  shoulder  two  skiagrams 
should  be  made  of  the  affected  joints. 

The  diagnosis  can,  as  a  rule,  be  readily  made  from  these  skia- 
grams. 

In  cases  of  the  hip  and  shoulder  dislocations,  the  empty  aceta- 
bular and  glenoid  cavities,  and  the  abnormal  position  of  the  heads 
of  the  femur  and  humerus,  can  be  easily  made  out.  In  old  dis- 
locations the  new  joint  can  be  distinctly  made  out  (Plate  LXX). 

In  congenital  dislocations  of  the  hip  joints,  which  have  been 
reduced,  the  former  position  of  the  head  of  the  femur  and  the 
lessened  depth  of  the  acetabular  cavity  are  distinctly  visible  on 
the  affected  side  (Plate  LXXII). 


—  i84  — 


PLATE  LXVIII. 

DISLOCATION    BACKWARDS    AND    UPWARDS    OF    BOTH    BONES    OF    THE    FOREARM- 

ANTERO-POSTERIOR   VIEW — FRACTURE   OF  THE   OLECRANON — 

SAME   CASE   AS    PLATE   LXIX. 


PLATE  LXVIII. 


—  i86  — 


PLATE  LXIX. 

DISLOCATION    BACKWARDS    AND    UPWARDS    OF    BOTH    BONES    OF    THE    FOREARM- 
LATERAL    VIEW — FRACTURE   OF   THE    OLECRANON — SAME 
CASE   AS    PLATE    LXVIII. 


PLATE  LXIX. 


— 188  — 


PLATE  LXX. 

DISLOCATION     DOWNWARDS,    FORWARDS     AND     INWARD    OF     THE     HEAD    OF     THE 
HUMERUS — OLD    DISLOCATION. 


The  glenoid  cavity  is  empty. 

The.  new  joint  can  be  distinctly  made  out. 


PLATE  LXX. 


— 190  — 


PLATE  LXXr. 

nnUBLE   CONGENITAL   DISLOCATION    OF   THE   HIPS — EXOSTOSIS   ON    THE   SHAFT   OF 
THE    LEFT    FEMUR. 

Both  acetabular  cavities  arc  empty. 

The  new  joints  above  on  tlic  dorsum  of  the  ilium  can  be  plainly  seen. 


'^^^ 


^ss- 


PLATE  LXXI. 


—  192  — 


PLATE  LXXIT. 

REDUCED   COXCESITAL   DISU)CAT10X   OF   THE   RIGHT    HIP. 

The  acetabular  cavity  on  the  right  side  is  not  as  deep  as  on  the  normal 
side. 

Just  below  the  acetabulum  is  a  depression,  which  represents  the  situation 
of  the  abnormal  position  of  the  head  before  reduction. 


PLATE  LXXII. 


—  195  — 


FOREIGN   BODIES. 


We  are  onl_v  concerned  in  this  chapter  with  the  location  of 
Foreign  Bodies  in  or  near  the  bones  and  joints  of  the  extremities. 
This,  we  believe,  can  be  done  in  every  instance  from  skiagrams 
talten  in  the  usual  manner,  without  the  use  of  any  special  instru- 
ment, by  remembering  and  applying  the  two  following  rules : 

First.    Whenever  a  foreign  body  is  imbedded  in  the  bone  it  is 
always  surrounded  by  a  light  zone,  first  described  by  the  author. 
Second.     The  closer  the  foreign  body  lies  to  the  X-rav  plate 
the  smaller,  the  darker,  and  the  sharper  will  its  shadow  be. 

When  the  foreign  body  is  imbedded  in  the  bone,  a  good  skia- 
graph shows  a  zone  completely  surrounding  it.  This  zone  is  of 
a  lighter  shade  than  that  of  the  bone  in  which  the  foreign  body 
is  imbedded.  Such  is  not  the  case  if  the  foreign  body  is  not  im'- 
bedded  in  the  bone,  even  though  the  latter  and  the  foreign  bodv 
both  he  in  the  path  of  the  X-rays  and  show  in  the  negative  in 
such  a  manner  that  from  one  single  skiagraph,  taken  without 
special  device  and  in  only  one  position  of  the  tube  and  part,  it 
would  be  impossible  to  tell  whether  the  foreign  body  was  in  front 
or  behind  or  in  the  bone,  except  for  the  presence  of  this  zone 
(Plates  LXXIII  and  LXXIV). 

It  follows  that  if  the  foreign  body  is  not  imbedded  in  the  bone, 
and  that  its  shadow  is  more  distinct  and  sharp  than  that  of  the 
latter,  it  must  necssarily  lie  closer  to  the  X-ray  plate  or  between 
the  bone  and  the  X-ray  plate.  In  an  antero-posterior  view  this 
would  mean  that  it  was  situated  behind  or  posterior  to  the  bone 
(Plates  LXXVn  and  LXXVUI). 

For  example,  we  suppose  a  skiagram  of  the  hip  taken  in  the 
usual  antero-posterior  position  and  showing  the  presence  of  a 
foreign  body.  The  absence  of  the  light  gray  zone  would  indicate 
that  the  foreign  body  was  not  imbedded  in  the  femur.  A  large, 
indistinct  shadow  with  an  outline  not  as  sharp  as  that  of  the  bolie 
would  indicate  further  that  the  foreign  bodv  was  in  front  of  the 
latter,  /.  c.  farther  removed  from  the  X-ray  plate  than  the  bone. 
It  for  any  reason  the  location  of  the  foreign  body  seemed 
doubtful  after  the  examination  of  this  skiagram,  and  as  it  cannot 
be  confirmed  by  a  lateral  view,  another  skiagram  should  be  made 
with  the  patient  lying  face  down,  that  is,  a  posterior-anterior 
view  of  the  hip.  instead  of  the  usual  antero-posterior  view. 

If  for  any  reason  the  location  of  the  foreign  bodv  seemed 
the  second  the  shadow  of  the  foreign  body  would  be  smaller, 
darker  and  more  distinct  and  sharp,  because  the  foreign  body 
would  be  lying  closer  to  the  X-ray  plate. 


— 196  — 


PLATE  LXXIII. 

GUN-SHOT    WOUND    OF    THE    RIGHT    THIGH — BULLET    LODGED    IN    THE    GREATER 
TROCHANTER. 

The  light-gray  zone  completely  surrounds  the  bullet. 

This  negative,  made  over  two  years  ago,  had  not  been  properly  washed 
after  fixing  and  it  turned  yellow.  This  accounts  for  the  poor  detail  and 
the  fact  that  the  acetabulum  head  and  neck  of  the  femur  are  lost. 


PLATE  LXXIII. 


—  198  — 


PLATE  LXXIV. 

GUN-SHOT   WOUND  OP  THE   KNEE — BULLET   LOViflEn   IN    THE   UPPER  END 
OF    THE    TIETA. 

The  light  gray  zone  completely  surrounds  the  bullet. 


PLATE  LXXIV. 


PLATE  LXXV. 

GUN-SHOT    WOUND    OF    THE    ARM — GUN-SHOT    FRACTURE    OF    THE    HUMERUS — ■ 
ANTERO-POSTERIOR  VIEW — SAME   CASE  AS   PLATE   LXXVI. 

The  small  circumscribed  black  shadow  at  the  upper  end  of  the  fracture 
line  is  a  fragment  of  the  splintered  bullet.  As  it  is  not  surrounded  by 
a  light  gray  zone  it  is  not  lodged  in  the  bone,  but  lies  posterior  to  the 
bone,  as  shown  in  the  next  Plate. 


PLATE   LXXV. 


PLATE  LXXVT. 

GUN-SHOT  WOUND  OF  THE  KNEE — LATERAL  VIEW — SAME  CASE  AS  PLATE  LXXVII. 
LATERAL     VIEW — SAME     CASE     AS     PLATE     LXXV. 

The  small  circumscribed  black  shadow  seen  in  the  center  of  the  bone 
shadow  is  a  fragment  of  the  splintered  bullet.  As  it  is  not  surrounded 
by  a  light  gray  cone  it  is  not  in  the  bone,  but  must  be  internal  or  external 
to  it.  When  the  negative  was  taken  the  ulnar  surface  was  lying  on  the 
plate,  and  the  shadow  lying  behind  the  humerus,  having  a  more  distinct 
outline,  was  lying  closer  to  the  plate,  i.  e.,  closer  to  the  ulnar  or  inner 
border  of  the  bone,  and  the  other  was  closer  to  the  radial  or  outer  border. 
Pl.nte  LXXV  shows  this. 


PLATE  LXXVI. 


—  204- 


PLATE  LXXVII. 

GUN-SHOT    WOUND   OF   THE   LEFT    KNEE — ANTERO-POSTERIOR    VIEW — SAME    CASE 
AS    PLATE    LXXVIII. 

The  small  circumscribed  black  shadow  seen  above  the  condyles  is  the 
bullet. 

As  it  is  not  surrounded  by  a  light  gray  zone  it  is  not  imbedded  in  the 
bone,  but  must  lie  anterior  or  posterior  to  it.  Since  the  outline  of  the 
bullet  is  sharper  than  that  of  the  bone  it  must  have  been  lying  between 
the  latter  and  the  plate  during  the  exposure.  It  must  therefore  lie  behind 
the  bone.    The  correctness  of  this  interpretation  is  seen  in  the  next  Plate. 


PLATE  LXXVII. 


2o6 


PLATE  LXXVIII. 

GUX-SHOT  WOUND  OF  THE  KNEE — LATERAL  VIEW — SAME  CASE  AS  PLATE  LXXVn. 

The  small  circumscribed  dark  gray  shadow  lying  behind  the  femur  and 
above  the  condyles  is  the  bullet. 

As  its  outline  is  neither  more  nor  less  distinct  than  that  of  the  bone 
it  must  be  lying  in  a  position  about  opposite  the  center  of  the  bone.  See 
preceding  Plate. 


PLATE  LXXVIII. 


Rd^ae  G762  C^l'^  LIBRARIES (hsi.stx) 
^  '^'^"?.9.W.^''^  3tlas  of  the  patholon 


RD36 
Granger 


G762 


-.-.■■  ry^Mg,».-»n»i!-.-.  >v--^v..--'.-jSfT>-ji&,'y«;&-a.y,-!;;-,T.x;,7, 


